386039_Well Construction - GW1_20100803

NONRESIDENTIAL WELL CONSTRUCTION RECORD RECEIVED
North Carolina Department of Environment and Natut al Resources- Division of Water Quality A U G 0 3 2010
WELL CONTRACTOR CERTIFICATION # 2581 Information Processing
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
( 704 )_ 872-7686
Area code- Phone number
2. WELL INFORMATION
SITE WELL ID #(if applicable) MW-8-D, S
Zip Code
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring D Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other ❑ (list use)
DATE DRILLED 07/12/10 - 07/13/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE COUNTY MECKLENBURG
5315 MONROE ROAD 28205
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑Slope ❑Valley ❑ Flat ❑Ridge 0 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 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 69 0/22 0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL') YES ❑ NO E
c. WATER LEVEL Below Top of Casing 14 0 FT
(Use "+" if Above Top of Casing)
DWU/tiUG
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 W i ht Material
From 0 0 To 64 0 Ft 1 INCH SCtT40 PVC
From 0 0 To 7 0 Ft 1 INCH SCH 40 PVC
From To Ft
7 GROUT Depth Material Method
From 0 0 To 3 0 Ft Portland bentonite SLURRY
From To Ft
From To Ft
8. SCREEN Depth Diameter Slot Size Material
From 64 0 To 69 0 Ft 1 0 in 010 in PVC
From 7 0 To 22 0 Ft 1 0 in 010 in PVC
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size Material
From 62 0 To 69 0 Ft 20-40 FINE SILICA SAND
From 5 0 To 22 0 Ft 20-40 FINE SILICA SAND
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 1 0 GRAVEUASPHALT
1 0 13 0 RED SILTY CLAY
13 0 29 0 TAN SILTY CLAY
29 0 45 0 GRAY SILTY SANDY CLAY
45 0 69 0 PARTIALLY WEATHERED ROCK
11 REMARKS
BENTONITE SEAL FROM 24 0 TO 62 0 FT & 3 0 TO 5 0 FT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15 WELL CONSTRUCTION STANDARDS AND THAT A COPY OF THIS
COf�HA EEN PROVIDED TO THE WELL NER
/ 07/16/10
SIGNATURE D W C 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

001(0-e_ tsi .