407277_Well Construction - GW1_20120827

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-21
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 07/12/12
4. WELL LOCATION:
2375 SOUTH 17TH STREET 28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Top 5.0 Bottom 20.0
CITY: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ValleyFiat ❑ Ridge DOther
LATITUDE 34 ° 11 • 57.0600 "DMS OR DD
LONGITUDE 77 ° 55 17.6000 " DMS OR DD
Latitude/longitude source: BPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
PANTRY - 464
• N/A
Facility Name
2375 SOUTH 17TH STREET
Facility ID# (if applicable)
Street Address
WILMINGTON
City or Town
THE PANTRY, INC
NC
State
28403
Zip Code
Contact Name
305 GREGSON DRIVE
(
Mailing Address
CARY
City or Town
NC 27511
State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 12.0
(Use "+" if Above Top of Casing)
NO q�
FT.
poi
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
*Top of casing terminated atlor 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):
Top Bottom Top Bottom
Top Bottom Top Bottom
: Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight
Top 0.0 Bottom 5.0 Ft. 2 INCH
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
: Top Bottom
Material
SCH 40 PVC
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
9. SCREEN: Depth Diameter Slot Size
Ft. 2.0 in. .010
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom 20.0
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 5.0
5.0 / 15.0
15.0 / 20.0
Method
SLURRY
Material
in. PVC
Size Material
Ft. 20-40
FINE SILICA SAND
Formation Description
BROWN SILTY SAND
DARK BROWN SILTY SAND
DARK BROWN COARSE SAND
AUG 272012 2012
4(1/6' s
•
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
I DO HEREBY CEFY THAT THIS WELL WAS CONST
• 15A NCAC 2C, L CONSTON T4NDARDS, THAT A COPY OF THIS
• RECORD HAS PR IDET THQ IWin/N'
SIG
TED IN ACCORDANCE WITH
07/27/12
RE OF CERTIFIED WELL CONTRACTOR DATE
: JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
bmit within 3Q days of cor,
ail Service `Center, Raleigi
©ivision,of:Water, (
I. Processina
Form GW-1 b
Rev. 2/09