407271_Well Construction - GW1_20120827

NONRESIDENTL4IL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company. Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-15
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)
CITY: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Walley VFlat ❑ Ridge ❑Other
LATITUDE 34 ° 11 ' 59.1000 "DMS OR
LONGITUDE 77 ° 55 19.1600 " DMS OR
Latitude/longitude source: VGPS ❑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
Street Address
DD
DD
Facility ID# (if applicable)
WILMINGTON NC 28403
City or Town • State Zip Code
THE PANTRY, INC
Contact Name
305 GREGSON DRIVE
Mailing Address
CARY NC 27511
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g/
c. WATER LEVEL Below Top of Casing: 11.0 FT.
(Use "+" if Above Top of Casing)
4 -L
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
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
7. CASING: Depth
Top 0.0 Bottom 5.0
Top Bottom
: Top Bottom
N/A
N/A
Bottom
Bottom
Bottom
Thickness/
Diameter Weight
Ft. 2 INCH SCH 40
Ft.
Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0 Ft.
: Top Bottom Ft.
: Top Bottom Ft.
Material
PORTLAND BENTONITE
Material
PVC
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft. 2.0 • in. .010 in. PVC
: Top Bottom Ft. in. in.
: Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 4.0 Bottom 20.0 Ft. 20-40
: Top Bottom
Top Bottom
11. DRILLING LOG
• Top Bottom
: 0.0 / 1.0
: 1.0 / 5.0
5.0 / 10.0
10.0 / 20.0
Ft.
Ft.
Material
FINE SILICA SAND
Formation Description
ASPHALT/GRAVEL
TAN SAND
GRAY SAND
DARK GRAY SAND
rr-
/AUG 2 7 2012
P0/2
12. REMARKS:InforiYiatioPro
cess •
BENTONITE SEAL FROM 3.0 TO 4.0 FEET 141QC),
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A N C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
EC ( D HAS BEEN PRO 1 D TO T4 WELL OWNER.
: f '6 07/27/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Form GW-lb
Rev. 2/09