407270_Well Construction - GW1_20120827

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1. WELL CONTRACTOR:
VINCE FEDERLE
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address g. WATER ZONES (depth):
STATESVILLE NC 28625 : Top Bottom Top Bottom
City or Town State Zip Code •
Top Bottom Top Bottom
( 704 ) 872-7686 : Top Bottom Top Bottom
Area code Phone number
: Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# : Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40 PVC
n P.7 ',7) --, 0
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
*Top of casing terminated atlor 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
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-14
3. WELL USE (Check One Box) Monitoring p1 Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 07/10/12
Top Bottom Ft.
: Top Bottom Ft.
: 8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTLAND BENTONITE SLURRY
Top Bottom Ft.
: Top Bottom Ft.
4. WELL LOCATION: : 9. SCREEN: Depth Diameter Slot Size Material
2375 SOUTH 17TH STREET 28403 ; Top 5.0 Bottom 20.0 Ft. 2.0 in. .010 in. PVC
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) ;Top Bottom Ft. in. in.
CITY: WILMINGTON COUNTY NEW HANOVER : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley wfFIat ❑ Ridge ❑ Other ; 10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 20.0 Ft. 20-40 FINE SILICA SAND
LATITUDE 34 ° 11 • 59.1900 "DMS OR DD
LONGITUDE 77 ° 55 ' 17.3800 " DMS OR 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
2375 SOUTH 17TH STREET
Street Address
WILMINGTON
City or Town
THE PANTRY, INC
Facility 1D# (if applicable)
NC 28403
State Zip Code
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 [/
c. WATER LEVEL Below Top of Casing: 11.0 FT.
(Use "+" if Above Top of Casing)
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0.0 / 1.0
1.0 / 5.0
5.0 / 10.0
10.0 / 20.0
TOPSOIL
TAN SAND
GRAY SAND
DARK GRAY SAND
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12. REMARKS:
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A N AC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• EC 9 D HAS BEEN PROV1 D TO T WELL OWNER. •
I-e 07/27/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09