410166_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
JAMES HESS
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# N/A
OTHER ASSOCIATED. PERMIT#Qf applicable)
SITE WELL ID #(it applicable) MW-2
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 11/06/12 - 11/07/12
4. WELL LOCATION:
2865 PINEY GREEN ROAD 28544
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: JACKSONVILLE COUNTY ONSLOW
TOPOGRAPHIC / LAND�/SETTING: (check appropriate box)
Slope CValley yl Flat ❑Ridge ❑Other
LATITUDE 34 ° 42 •59.3800 "DMS OR DD
LONGITUDE 77 ° 19 12.2000 " DMS OR DD
Latitude/longitude source: V3PS [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 - 3126
N/A
Facility Name Facility ID# (if applicable)
2865 PINEY GREEN ROAD
Street Address
JACKSONVILLE NC 28544
City or Town State Zip Code
THE PANTRY, INC
Contact Name
PO BOX 8019
Mailing Address
CARY
City or Town
NC 27512
State Zip Code
( - )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 13.0
(Use "+" if Above Top of Casing)
NO d
FT.
3550
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. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. Pom1ANo BENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
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 Material
Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom - Ft.
11. DRILLING LOG
Top Bottom
0.0 / 7.0
7.0 / 17.0
17.0 / 20.0
FINE SILICA SAND
Formation Description
BROWN CLAYEY SAND
GRAY SILTY SAND
BROWN SILTY SAND
OFF
12. REMARKS:
BENTONITE SFAL FROM 3 0 TO 4 0 FEET
Ivy�jC•�5°
I DO HEREBY CERTIFY AT THIS WELL WAS CONSTRUCTEP7J ACCORDANCE WITH
15A NCAC 2C. WELL •• STRUCTJf 48 ANet.f)DS, AND TI jyT A COPY OF TFItS^",`
RECORD HAS BEE .1+•. •- 0
' us 11/28/12 r r.�: ,T
SIGNATU/VOF CERTIFIED WELL CO);1TR!A„(TbR
JAMES HESS < C�5
PRINTED NAME OF PERSON CONSTRUCTING HE WELL
ubmit within 30 days of completion to Duvision of Water Quality;
1617 Mail Servuce Center -,.Raleigh, NG+27699 161 Phone "(919) 807-630Q'
(�TiEa
Form GW-1 b
Rev. 2/09