389511_Well Construction - GW1_20101119

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NONRESIDENTIAL WELL CONSTRUCTION RECORD
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
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-18
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10/12/10 - 10/14/10
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 ❑Valley ❑ Flat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE _
LONGITUDE
May be in degrees,
minutes, seconds or
in a decimal tormat
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 SEARS FACILITY - 8075
STREET ADDRESS 11407 GRANITE STREET
CHARLOTTE
NC 28273
City or Town State
CONTACT PERSON OFFICE ENVIRONMENTS
Zip Code
MAILING ADDRESS 11407 GRANITE STREET
CHARLOTTE NC
28273
City or Town State
( )-
Area code - Phone number
5. WELL DETAILS
a TOTAL DEPTH 100 0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c WATER LEVEL Below Top of Casing 12 0 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 Thicknttess/
From 0 0 DToth 90 0 Ft 2 IIDINCeettHef SCi-Ta0 Material
From 0 0 To 23 0 Ft 6 INCH SCH 40 PVC
From To Ft
7. GROUT Depth Material Method
From 0 0 To 84 0 Ft Portland bentonite SLURRY
From 0 0 To 23 0 Ft Portland bentonite SLURRY
From To Ft
8. SCREEN Depth Diameter Slot Size Material
From 90 0 To 100 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 88 0 To 100 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To Formation Description
0 0 5 0 BROWN CLAY
5 0 17 0 BROWN SANDY SILT
17.0 20 0 WEATHERED ROCK
20 0 100 0 WHITE/GRAY ROCK
w m-..,,,fl _F v7 i..� i ..
NI01/ 11 ink 'm i n
• Y .4 LU it,
Infnrmatir,n vr: ,.-,.r, .
^ . I 1.....,+
DWQ/BOG
11. REMARKS
BENTONITE SEAL FROM 84 0 TO 88 0 FT
1 D0 HEREBY CERTIFY THAT THIS WELL WAS ONSTRUCTED IN ACCORDANCE WITH
15A NCAC WELL CONSTR �� TIO '• ifs%'%' RDS, AND THAT A COPY OF THIS
RECORD /'S BEEN PR P P 0.,.'' ELL OWNER
" 10/19/10
SIGNA, RE OF CERTIFIED WELL CONTRACTOR DATE
JA''ON MANTAK
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 clays. Attn: Information Mgt.,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568
Form GW-1b
Rev 7/05