407276_Well Construction - GW1_20120827

1.6
1. WELL CONTRACTOR:
JAMES HESS
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
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-20
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
irrigation❑ Other ❑ (list use)
DATE DRILLED 07/11/12
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 Qf Flat ❑ Ridge ❑Other
LATITUDE 34 011 ' 58.8500 " DMS OR
LONGITUDE 77 ° 55 22.8200 DMS OR
DD
DD
Latitude/longitude source: 3PS ❑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 0 NO q/
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
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
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth
Material
Ft. PORTLAND BENTONITE
Material
PVC
Method
SLURRY
Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft.
: Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 4.0
: Top
Top
11. DRILLING LOG
:. Top Bottom
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
0.0 / 3.0
2.0 in. .010 in. PVC
Bottom 20.0 Ft.
Bottom Ft.
Bottom Ft.
3.0 / 15.0
15.0 / 20.0
in. in.
in. in.
Size Material
20-40
FINE SILICA SAND
Formation Description
BROWN SILTY SAND
GRAY SILTY SAND
BROWN SILTY SAND
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12. REMARKS:
. BENTONITE SEAL FROM 3.0 TO 4.0 FEET
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I DO HEREBY
• 15A NCAC 2
RECORD
•
TIFY THAT THIS WELL WAS CON
ELL COTI TANDARD
TO •
UCTED IN ACCORDANCE WITH
AND THAT A COPY OF THIS
SI V. A TURE OF CERTIFIED WELL CONTRACTOR
JAMES HESS
07/27/12
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
within
it Service Cen#er, Raiei
•
mp(etion to: tDivisio
Form GW-1 b
Rev. 2/09