405675_Well Construction - GW1_20120618

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
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
State
28625
Zip Code
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #(if applicable) MW-9
3. WELL USE (Check One Box) Monitoring 1 Municipal/Public p
Industrial/Commercial p Agricultural 0 Recovery p Injection 0
Irrigationo Other p (list use)
DATE DRILLED 04/25/12
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 D Valley 'Flat °Ridge ❑ Other
LATITUDE 34 ° 11 ' 58.6800 "DMS OR DD
LONGITUDE 77° 55 ' 21.3600 " DMS OR DD
Latitude/longitude source: 3PS DTopographic 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
Contact Name
305 GREGSON DRIVE
Facility ID# (if applicable)
NC 28403
State Zip Code
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 p NO rit
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
�nair Serv,ce Center,
atei
'ision'� ..
3550
I ;‘,
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 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, PORTLAND BENTONITE 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
Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
•
•
•
•
•
•
•
•
•
•
•
•
.
•
•
•
•
•
.
•
•
•
•
0.0 / 20.0
/
Size Material
FINE SILICA SAND
Formation Description
BROWN/TAN SAND
II
•
Inforrination Processing
OWCYBOG
12. REMARKS:
BENTONITE SEALFROM 3.0 TO 4,0 FEET
I DO HEREBY CERTIF
• 15A NCAC 2C, WE
• RECORD HAS B
THAT THIS WELL WAS CONSTRUCT . D IN ACCORDANCE WITH
ONSTRUCTION STANDARDS, AND /AT A COPY OF THIS
PROVIDEd'QCfTHE' IC �L OWNER.
SIGNA E OF CERTIFIED WELL C • TRACTOR
: JA
S HESS
PRINTED NAME OF PERSON CONSTRUCTING THE .WELL
JUN 18 2i2
Form GW-1 b
Rev. 2/09
a:
orma.