410458_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
Welt 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#0( applicable)
SITE WELL ID #(ifapplicable) MW-7
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Inigalionp 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 ❑Valley giFlat 0 Ridge 0 Other
LATITUDE 34 ° 42 ' 59.3800 "DMS OR
LONGITUDE 77 ° 19 ' 12.2000 "DMS OR
Latitude/longitude source: IMPS pl'opographic 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
DD
DD
Facility Name
2865 PINEY GREEN ROAD
Facility ID# (if applicable)
Street Address
JACKSONVILLE
City or Town
THE PANTRY, INC
Contact Name
PO BOX 8019
NC 28544
State Zip Code
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 CRC
FT.
3550
d. TOP OF CASING 1S 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
Top 0.0 Bottom 3.0 Ft. PORTIAND BENTONITE
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Method
SLURRY
Material
Top 5.0 Bottom 20.0 Ft. 2.0 in. .010 in. PVC
Top
Top
Bottom
Bottom
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom 20.0
Top
Top
Ft. in. in.
Ft. in. in.
Size Material
Ft. 20-40
Bottom Ft.
Bottom Ft.
FINE SILICA SAND
11. DRILLING LOG
Top Bottom
0.0
7.0
17.0
7.0
17.0
20.0
Formation Description
BROWN CLAYEY SAND
GRAY SILTY SAND
BROWN SILTY SAND
/ Uc
/r
/ °1,74,4,z9 ,
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 4 0 FEET
I DO HEREB i RTIFY THAT THIS W LL WAS CO
15A NCAC Q WELL C0NCVROCT�'tjt j�I�SSTAAgNIDDARpg'AND THAT A COPY OF THIS
RECOR�;I' .J -'7�T' VAL rvGRRR
Sb
RUCTED IN ACCORDANCE WITH
11/28/12
ATURE OF CERTIFIED WELL CONTRA TC`�OR . DATE
JAMES HESS
PRINTED NAME OF PERSON CO('ST 2U � ING 9H
S'ubmitTwtthin 30 days of completion to Division of Water Quality
1617 Mail Serowe Center, Raleigh, NC 27699 167 Phone �[phone]
Form GW-1 b
Rev