384231_Well Construction - GW1_20100603

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural 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-15
STATE WELL PERMIT#(if applicable)
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring El Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/17/10 - 05/18/10
Recovery ❑ Injection ❑
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 State
CONTACT PERSON UNIVAR USA, INC
MAILING ADDRESS
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 E
c. WATER LEVEL Below Top of Casing 22 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
g WATER ZONES (depth)
From To
From To
From To
6 CASING
Depth
From 0 0 To 15 0 Ft
From To Ft
From To Ft
Amount N/A
From
From
From
2 INCHer
To
To
To
Thickness/
Weight
CRo
7 GROUT Depth Material
From 0 0 To 3 0 Ft Portland bentonite
From To Ft
From To Ft
8 SCREEN Depth Diameter
From 15 0 To 25 0 Ft 2 0 in
From To Ft in
From To Ft in
Method
SLURRY
Slot Size Material
010 in PVC
In
in
9. SAND/GRAVEL PACK
Depth Size Material
From 12 0 To 25 0 Ft 20-40 FINE SILICA SAND
From To Ft
From To Ft
10 DRILLING LOG
From To
00 100
100 250
Formation Description
RED SILTY CLAY
TAN SILT
ji / f �" 0 3•
ZU
11 REMARKS uP'/`�`/0,7 ��
BENTONITE SEAL FROM 3 0 TO 12 0 FT Clio/°%,;,_
WUnr
I, DO HEREBY CERTI
5A' CAC 2C, WEL
EC RD HAS BEE
THAT THIS WELLO AS CONSTRUCTED IN ACCORDANCE WITH
ON ;SUCTION Si NDARDS, AND THAT A COPY OF THIS
RO 0 TO T.. WELL 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