389510_Well Construction - GW1_20101119

NONRESIDENTIAL WELL CONSTRUCTION RECC(4$Oi 5
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2580
1. WELL CONTRACTOR
JASON MANTAK
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-17
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 10/11/10 - 10/12/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION
CITY CHARLOTTE
11407 GRANITE STREET 28273
COUNTY MECKLENBURG
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING
❑ Slope EValley ❑ Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal tormat
Latitude/longitude source DGPS ❑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 SEARS FACILITY - 8075
STREET ADDRESS 11407 GRANITE STREET
CHARLOTTE
NC 28273
City or Town State Zip Code
CONTACT PERSON
OFFICE ENVIRONMENTS
MAILING ADDRESS 11407 GRANITE STREET
CHARLOTTE NC 28273
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS.
a. TOTAL DEPTH
175 0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL/ YES ❑ NO E
c. WATER LEVEL Below Top of Casing DRY FT
(Use "+" if Above Top of Casing)
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 Wel ht
From 0 0 To 141 0 Ft 2 INCH SCi�4o
From 0 0 To 120 0 Ft 61/4 INCH
From To Ft
7. GROUT Depth Material Method
From 0 0 ro 120 0 Ft Portland bentonite SLURRY
From 0 0 To 120 0 Ft Portland bentonite SLURRY
From To Ft
Material
VC real
188 STEEL
8. SCREEN Depth Diameter Slot Size Material
From 141 0 To 151 0 Ft 2 0 in 010 In PVC
From To Ft in in
From To Ft in in
9 SAND/GRAVEL PACK
Depth Size
From 139 0 To 151 0
Ft 20-40
From To Ft
From To Ft
Material
FINE SILICA SAND
10 DRILLING LOG
From To Formation Description
0 0 1 0 ASPHALT/GRAVEL
10
70
22 0
27 0
35 0
70
22.0
27 0
35 0
175 0
BROWN SILTY CLAY
BROWN SANDY SILT
TAN SANDY SILT
WEATHERED ROCK
WHITE/GRAY ROCK
Nay 1 ci %illfl
11 REMARKS Information 1'rCcc:ssing Unit
BENTONITE SEAL FROM 120 0 TO 139 0 PTNQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CON
15A NCAC 2C, W LL CONSTRUCTIO
RECORD HAS B N PROVIDED T
TRUCTED IN ACCORDANCE WITH
AND THAT A COPY OF THIS
WNER
10/19/10
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