384457_Well Construction - GW1_20100610

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1 WELL CONTRACTOR
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE
NC 28625
City or Town State Zip Code
( 704 )_ 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-3D
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring E Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/25/10 - 05/28/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
COUNTY MECKLENBURG
2100 NORTH CHURCH STREET 28206
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map and
attached to this form d not using GPS)
4 FACILITY- is the name of the business where the well is located
FACILITY ID #(if applicable)
NAME OF FACILITY FMR CLAIRE MANUFACTURING
STREET ADDRESS 2100 NORTH CHURCH STREET
CHARLOTTE
NC 28206
City or Town State Zip Code
CONTACT PERSON CLAIRE - SPRAYWAY
MAILING ADDRESS 1005 WESTGATE DRIVE
ADDISON IL 60101
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH 68 5 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c WATER LEVEL Below Top of Casing 27 0 FT
(Use "+" if Above Top of Casing)
3 4"7
d TOP OF CASING IS 0 0 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) N/A METHOD OF TEST N/A
f DISINFECTION Type N/A Amount N/A
g WATER ZONES (depth)
From To From To
From To From To
From To From To
6 CASING Thickness/
Depth Diameter We 1q ht Material
From 0 0 To 58 5 Ft 2 INCH SCli40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 54 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 58 5 To 68 5 Ft 2 0 rn 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 56 0 To 68 5 Ft 20-40 FINE SILICA SAND
From To Ft
From_ To Ft
10 DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEL
1 0 20 0 RED SILTY CLAY
20 0 34 0 BROWN SILTY CLAY
34 0 58 0 TAN SILTY CLAY
58 0 68 5 PARTIALLY WEATHERED ROCK
tr", rra ,_
tAI
II a
..L.t•t 1 0 201f1
Inru;
,,.,„,L, i r- dth,,,"
asing Unit
11 REMARKS DWQ/B6G
BENTONITE SEAL FROM 54 0 TO 56 0 FT
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RD H BEEN PROVIDED TO THE WNER
�..` 06/02/10
SIMIXTUR IED LL CO ACTOR DATE
BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568
Form GW-lb
Rev 7/05