406388_Well Construction - GW1_20120820

NONRESIDENTIAL 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
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) RW-3
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery iilnjection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/31/12
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 ❑Valley itFlat ❑ Ridge ❑Other
LATITUDE 34 ° 19 9.3200 " DMS OR DD
LONGITUDE 77 ° 92 ' 17.2300 " DMS OR DD
Latitude/longitude source: VPS ❑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 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 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 Ii
c. WATER LEVEL Below Top of Casing: 10.0 FT.
(Use "+" if Above Top of Casing)
thin 30 days of completion'•
Ma�I,;Servace Center, Raleigh,'NC 27E
'�visIo
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 Bottom
: Top Bottom Top Bottom
: Top Bottom Top Bottom
• Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 4 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 .Bottom 3.0 Ft. PORTIAND BENTONITE
: Top Bottom Ft.
: Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft. 4.0 in. .010 in. PVC
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom
Top
Top
Bottom
Bottom
11. DRILLING LOG
: Top Bottom
0.0 / 1.0
Size
20.0 Ft. 20-40
1.0 / 20.0
Ft.
Ft.
Material
FINE SILICA SAND
Formation Description
ASPHALT/GRAVEL
GRAY SILTY SAND
taiRy
8,11 ri ,
12. REMARKS:
: BENTONITE SEAL FROM 3,0 TO 4.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15 NC • 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RE• • - ' HAS BEEN P OVI * TO TH LL OWNER.
•
:i •,. _
06/18/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING-THEWELL
•
Water Quali
r ;�♦
rmation: rocessi
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Re'v. 2/09