384229_Well Construction - GW1_20100603

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Catolina Department of Envnonment and Natui al Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2579
1 WELL CONTRACTOR
DANNY SUMMERS
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) VEW-13
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 05/17/10 - 05/18/10
TIME COMPLETED AM ❑ PM ❑
3 WELL LOCATION
CITY CHARLOTTE
3930 GLENWOOD DRIVE 28208
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 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 FORMER UNIVAR
STREET ADDRESS 3930 GLENWOOD DRIVE
CHARLOTTE
NC 28208
City or Town
CONTACT PERSON
MAILING ADDRESS
State
UNIVAR USA, INC
Zip Code
17425 NE UNION HILL ROAD
REDMOND WA
98052
City or Town State
( )-
Area code - Phone number
5 WELL DETAILS
a TOTAL DEPTH 25 0 FEET
Zip Code
b DOES WELL REPLACE EXISTING WELL') YES ❑ NO El
c WATER LEVEL Below Top of Casing 22 0 FT
(Use "+" if Above Top of Casing)
3
4 `w ei
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 NIA
f DISINFECTION Type N/A
g. WATER ZONES (depth)
From
From
From
6 CASING
From 0 0
From
From
To
To
To
Depth
To 15 0
7 GROUT
From 0 0
From
From
Ft
To Ft
To Ft
Depth
To 30 Ft
To Ft
To Ft
8. SCREEN Depth
From
From
From
Amount NIA
From
From
From
INCeter
Material
To
To
To
Thickness/
`SCI-T40 PVC Material
Portland bentonite
Method
SLURRY
Diameter Slot Size Material
15 0 To 25 0 Ft 2 0 in 010 in PVC
To Ft in in
To Ft in in
9 SAND/GRAVEL PACK
Depth
From 12 0 To 25 0
Size
Ft 20-40
From To Ft
From To Ft
10 DRILLING LOG
From To
00 100
100 250
Material
FINE SILICA SAND
Formation Description
RED SILTY CLAY
TAN SILT
3
worm._ Z0i0
11 NITTE SEAL FROM 3 0 TO 12 0 FT RKS D�V ' '
ssAnn
BENTOIOG•
u,,,
I DO HEREBY CERTIFY THAT THIS WELL
1 A,� CAC 2C, WELL STRUCTION STRUCTION S
C RD HAS BEEN (WI (JVi 50 TO THE
CONSTR77lgtED IN ACCORDANCE WITH
ARDS AND THT,A COPY OF THIS
L OWNER
05/25/10
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
DANNY SUMMERS
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