407273_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-17
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 07/10/12
4. WELL LOCATION:
2375 SOUTH 17TH STREET 28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
GITy: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Valley VFlat ❑ Ridge ❑Other
LATITUDE 34 ° 11 ' 57.4800 " DMS OR
LONGITUDE 77 ° 55 ' 22.7600 " DMS OR
Latitude/longitude source: L(GPS ❑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
DD
DD
Facility Name Facility ID# (if applicable)
2375 SOUTH 17TH STREET
Street Address
WILMINGTON NC 28403
City or Town State Zip Code
THE PANTRY, INC
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 ❑
NO q/
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
Top 4.0
�f z
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):
Top Bottom Top
Top Bottom Top
: Top Bottom Top
Bottom
Bottom
Bottom
•
Thickness/
: 7. CASING: Depth Diameter Weight
Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
9. SCREEN: Depth Diameter
Top 5.0 Bottom 20.0 Ft. 2.0 in.
Top Bottom Ft. in.
Top Bottom Ft. in.
Material
PVC
Method
SLURRY
Slot Size Material
.010 in. PVC
10. SAND/GRAVEL PACK:
Depth
Bottom 20.0
in.
in.
Size Material
Ft. 20-40
: Top Bottom Ft.
Top Bottom Ft.
•
11. DRILLING LOG
:. Top Bottom
0.0 / 1.0
1.0 / 2.0
210 / 5.0
5.0 / 20.0
FINE SILICA SAND
Formation Description
BROWN SILTY SAND
GRAY SILTY SAND
LIGHT BROWN SILTY SAND
BROWN SILTY SAND
fry► ,;
i.'iAU6 212012
n yt
AUG
/
1• 2. REMARKS:
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET
forte
4.
I DO HEREBY CERT
• 15A NCAC 2C,
RECORD HAS B
SIGN
THAT THIS WELL WAS CONSTRU
CONSTRUCTION STANDARDS, AN
PROVIDE O THE W LL OWNE
E OF CERTIFIED WELL C
: JA ES HESS
D IN ACCORDANCE WITH
HAT A COPY OF THIS
07/27/12
NTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
completic
aleigh, NC.
►rlmation
�cessin
Form GW-1 b
Rev. 2/09