384459_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
STATESVILLE
176 COMMERCE BLVD
NC 28625
City or Town State Zip Code
( 704 )_ 872-7686
Area code- Phone number
2 WELL INFORMATION
SITE WELL ID #(if applicable) MW-13
STATE WELL PERMIT#Of applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ® 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 appropnate 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 if 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 Zip Code
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 73 0 FEET
b DOES WELL REPLACE EXISTING WELLS YES ❑ NO Ej
c WATER LEVEL Below Top of Casing 21 0 FT
(Use "+" if Above Top of Casing)
3J44Z.. 9
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 iQ ht Material
From 0 0 To 63 0 Ft 2 INCH SCH 40 PVC
From To Ft
From To Ft
7 GROUT Depth Material Method
From 0 0 To 59 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 63 0 To 73 0 Ft 2 0 in 010 in PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 61 0 To 73 0 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 73 0 PARTIALLY WEATHERED ROCK
JUN 1 0 701n
inforrnarion Proc: ssarlg Unit
11 REMARKS DWQ/BOG
BENTONITE SEAL FROM 59 0 TO 61 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A AC 2C WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
HAS BEEN PROVIDED TO TH LL OWNER
06/02/10
5n, TIFIE E L ACT 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

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