406386_Well Construction - GW1_20120820

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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
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) RW'I
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery dlnjection ❑
Irrigation❑ Other 0 (list use)
DATE DRILLED 05/31/12
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 Flat ❑Ridge ❑Other
LATITUDE 34 ° 19 94.6800 " DMS OR
LONGITUDE 77
° 92 19.5400 " DMS OR
DD
DD
Latitude/longitude source: VOIDS ['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
Facility ID# (if applicable)
WILMINGTON NC 28403
City or Town State Zip Code
THE PANTRY, I N C
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 [i
c. WATER LEVEL Below Top of Casing: 10.0 FT.
(Use "+" if Above Top of Casing)
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^Submit within 30 da, s of cor _..:letion t
Y 617 Mail `Service ,Center, Raleigh; NC 27E
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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): NIA METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
: Top Bottom Top
7. CASING: Depth Diameter
Top 0.0 Bottom 5.0 Ft. 4 INCH
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth
Top
Top
: Top Bottom
9. SCREEN: Depth
0.0 Bottom 3.0
Bottom
Top 5.0
Top
Top
Bottom
Bottom
Bottom
Thickness/
Weight Material
SCH 40 PVC
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
Method
SLURRY
Diameter Slot Size Material
Bottom 20.0 Ft. 4.0
Bottom Ft.
Bottom Ft.
in. .010 in. PVC
in.
in.
10. SAND/GRAVEL PACK:
Depth Size
Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
•
11. DRILLING LOG
Top Bottom
0.0 / 1.0
1.0 / 20.0
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12. REMARKS:
. BENTONITE SEAL FROM 3.0 TO 4.0 FEET
in.
in.
Material
FINE SILICA SAND
Formation Description
ASPHALT/GRAVEL
GRAY SILTY SAND
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I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORD ' BEEN PROVIDED TO THE WELL OWNER.
.
SIGNA
URE • F RTI IED WEL
06/ 18/ 12
DATE
: VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THEWELL ,,:. :,,.•, F , ;
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