410460_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#(ir applicable)
SITE WELL ID Nil applicable) MW-9
3: WELL USE (Check One Box) Monitoring tj Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
IrrigationD Other ❑ (list use)
DATE DRILLED 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 ❑Valley IgirFlat ❑Ridge ❑Other
LATITUDE 34 ° 42 ' 59.3800 " DMS OR DD
LONGITUDE 77 ° 19 ' 12.2000 " DMS OR DD
Latitude/longitude source: MPS ❑ropographic map
(location of well must be shown an 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 NC 27512
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 qt
c. WATER LEVEL Below Top of Casing: 13.0 FT.
(Use "+' if Above Top of Casing)
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
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
Material
Ft. PORTWND BENrONnE
Top Bottom Ft.
Top Bottom Ft.
Material
PVC
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0
Top
Top
Bottom 20.0 Ft. 2.0 in.
Bottom Ft. in.
Bottom Ft. in.
.010 in. PVC
in.
in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
FINE SILICA SAND
11. DRILLING LOG
Top Bottom Formation Description
0.0 / 7.0
7.0 / 17.0
17.0 / 20.0
/
/
BROWN CLAYEY SAND
GRAY SILTY SAND
BROWN SILTY SAND
12. REMARKS: E"}4 Or
r`
BFNTONITF SEAL FROM 3 0 TO 4 0 FEEt-:i
,?r G 19
1 DO HEREBY /r -TIFY THAT THIS WELL WAS CON UCTED IN ACCORDANCE WITH
15ANCAC 2rJ ELL COT TANDARD ND THAT A COPY OF THIS
RECORD /, EEN •' OVIgEp TO J11WAL O ER
SI' ATURE OF CERTIFIED WELL CONTF)ACTOR l' """BATE
JA JAMES HESS at %3
,,�
PRINTED NAME OF PERSON CONSTRUCTINGtTHE'WELL
Submit within 30 days `of Completion to Division of Water Quality"
1617 Marl Service Center, Raleigh, NC 27699 16! Phone [phone];
Form GW-1 b
Rev. 2/09