405674_Well Construction - GW1_20120618

( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION: Thickness/
7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# ; Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40 PVC
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
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WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
3550
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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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
Street Address
STATESVILLE g. WATER ZONES (depth):
City or Town N C 28625 :Top Bottom Top Bottom
State Zip Code
Top Bottom Top Bottom
: Top Bottom Top Bottom
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MIN-8
3. WELL USE (Check One Box) Monitoring d Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
irrigation❑ Other 0 (list use)
DATE DRILLED 04/25/12
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 t Size Material
2375 SOUTH 17TH STREET 28403 = Top 5.0 Bottom 20.0 Ft. 2.0 in.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) .010 in. PVC
.. Top Bottom Ft. in. in.
CITY: WILMINGTON COUNTY NEW HANOVER : Top Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Walley grFlat ❑ Ridge ❑Other ; 10. SAND/GRAVEL PACK:
LATITUDE 34 ° 11 57.6800 „ DMS OR Depth Size Material
DD : Top 4.0 Bottom 20.0 Ft. 20-40 FINE SILICA SAND
LONGITUDE 77 ° 55 18.3400 " DMS OR DD
• Top Bottom Ft.
(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.) 1 To RILLING LOG
p Bottom
PANTRY - 464 N/A
Facility Name
2375 SOUTH 17TH STREET
Street Address
WILMINGTON NC 28403
City or Town State Zip Code
THE PANTRY, INC
Facility ID# (if applicable)
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 it
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
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0.0 / 20.0
Latitude/longitude source: Q, 3PS ❑Topographic map
Top Bottom Ft.
Formation Description
BROWN/TAN SAND
OwariteIG
413
12. REMARKS:
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET
I DO HEREBY C- IFY THAT. THIS WELL WAS CONST'.•CTED IN ACCORDANCE WITH
• 15A NCAC 2C LL CONST Ti TANDARDS, ` D THAT A COPY OF THIS
RECORD H •/EEN P; OVI D TO T MOW r R.
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SI RE OF CERTIFIED WELL CONTRACTOR
04/30/12
DATE
: JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE;WELL