405676_Well Construction - GW1_20120618

YONRESIDENTIAL WELL . CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
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:
WELL CONSTRUCTION PERMIT#
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-1 0
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Cornmerciai 0 Agricultural 0 Recovery 0 Injection 0
Irrigation Other 0 (list use) •
DATE DRILLED 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)
❑ Slope ❑ Valley wf Flat 0 Ridge ❑ Other
LATITUDE 34 ° 11 , 56.2700 „ DMS OR DD
LONGITUDE 77 ° 55 ' 20.5600 „ DMS OR DD
Latitude/longitude source: VGPS ❑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 ❑ NO Lj
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
days of complet�n `,
Pr;
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 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
•
7. CASING: Depth
Thickness/
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 Method
Top 0.0 Bottom 3.0 Ft. PORT1ANDBENTONITE SLURRY
Top Bottom Ft.
: Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 20.0 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 4.0 Bottom 20.0 Ft. 20-40
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
FINE SILICA SAND
Formation Description
0.0 / 20.0 BROWN/TAN SAND
bilmrafte
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
: I DO HEREBY CERTIF THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WEL ' ONSTRUCTION STANDARDS, AND : • T A COPY OF THIS
RECORD HAS BE • �PROVID H L OWNER.
: Lehi / (..)0� 04/30/ 12
"
: SIGNA OF CERTIFIED WELL C
: JA SHESS
•-' RACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THEIWELL
IVISIOn of Wafer Qua
orrnafton ocessin
Form
201z