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NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natut al 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-2D
STATE WELL PERMIT#(if 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 07/12/10 - 07/13/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE
5315 MONROE ROAD 28205
COUNTY MECKLENBURG
(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 ID 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 A CLEANER
STREET ADDRESS 5315 MONROE ROAD
CHARLOTTE
NC 28205
City or Town State
CONTACT PERSON NCDENR
Zip Code
MAILING ADDRESS 601 OBERLIN ROAD
CHARLOTTE NC
28205
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS
a. TOTAL DEPTH 73 0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL/ YES ❑ NO
c WATER LEVEL Below Top of Casing 14 0 FT
(Use "+" if Above Top of Casing)
AUG 0 3 2010
Information Processing Unit
DWQ/BOG
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 Weight Material
From 0 0 To 68 0 Ft 2 INCH SC1-T40 PVC
From To Ft
From To Ft
7. GROUT Depth Material Method
From 0 0 To 63 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8 SCREEN Depth Diameter Slot Size Material
From 68 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 66 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/ASPHALT
1 0 13 0 RED SILTY CLAY
13 0 29 0 TAN SILTY CLAY
29 0 45 0 GRAY SILTY SANDY CLAY
45 0 73 0 PARTIALLY WEATHERED ROCK
11. REMARKS
BENTONITE SEAL FROM 63 0 TO 66 0 FT
1130 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
EEN PROVIDED TO THE WE NER
07/16/10
D W CO OR 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. (919) 733-7015 ext 568.
Form GW-1b
Rev 7/05