405679_Well Construction - GW1_20120618

{
1. WELL CONTRACTOR:
JOHNNY BURR
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3098
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
( 704 ) 872-7686
Area code Phone number
•
2. WELL INFORMATION: Thickness/
7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# ; Top 0.0 Bottom 40.0 Ft. 2 INCH SCH 40 PVC
NC 28625
State Zip Code
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 NIA Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) DMW-1
3. WELL USE (Check One Box) Monitoring li Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationD Other 0 (list use)
DATE DRILLED 04/25/12 - 04/26/12
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)
D Slope [Walley 'Fiat ❑Ridge D Other
LATITUDE 34 ° 11 ' 58.0300 " DMS OR DD
LONGITUDE 7=° 55 • 18.7000 " DMS OR DD
Latitude/longitude source: WIGPS Dfopographic 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 ID# (if applicable)
_ NC
State
28403
Zip Code•
Top 0.0 Bottom 35.0 Ft. 6 INCH SCH 40 PVC
: Top Bottom Ft.
: 8. GROUT: Depth
Top 0.0 Bottom 34.0
Top 0.0 Bottom 35.0
: Top Bottom Ft.
Material
Ft. PORTLAND BENTONITE
Ft. PORTL.AND BENTONITE
Method
SLURRY
SLURRY
: 9. SCREEN: Depth Diameter Slot Size Material
Top 40.0 Bottom 45.0 Ft. 2.0 in. .010 in. PVC
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 38.0 Bottom 45.0 Ft. 20-40
FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
: • 0.0 / 0.5 CONCRETE
0.5 / 5.0
• 5.0 / 12.0
12.0 / 40.0
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: 45.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES D NO gi
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
: Division
nan Service Cenfer, Raleigh
40.0 / 45.0
/
12. REMARKS:
TAN SAND
BROWN SAND
WHITE SAND
TAN/WHITE CLAY
RP s1Sy +!
N
: BENTONITE SEAL FROM 34,0 TO 38.0 FEET
irr111
-
Unit
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STAND s S, AND THAT A COPY OF THIS
• RECORD HAS BEEN PROVIDED TO THE WE OWNER.
SIGNA
: J. NY BURR
ED WEL
04/30/12
ONTRACTOR.
......DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
cessing
JUN 1 .ulz
Form GW-1 b
Rev. 2/09