405670_Well Construction - GW1_20120618

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quali
ty
ty
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor CompanyAame
176 COMMERCE BLVD
("7",
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
Street Address
STATESVILLE g. WATER ZONES (depth):
NC 28625 Top Bottom Top
City or Town State Zip Code :
Top Bottom Top
( 704 ) 872-7686 '
Top Bottom Top
Area code Phone number
•
2. WELL INFORMATION: Thickness/
7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT# ; Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #(if applicable) MIN-4
3. WELL USE (Check One Box) Monitoring ri Municipal/Public 0
Industrial/Commercial p Agricultural 0 Recovery p Injection 0
Irrigationp Other 0 (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)
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
: Top Bottom
9. SCREEN: Depth
Material
Ft. PORTLAND BENTONITE
Ft.
Ft.
Bottom
Bottom
Bottom
Material
PVC
Method
SLURRY
Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft.
: Top Bottom Ft.
CITY: WILMINGTON COUNTY NEW HANOVER : Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope [Valley (Flat p Ridge DOther
LATITUDE 34 ° 11 58.4800 N DMS OR DD
LONGITUDE 77 _° 55 18.2200 " DMS OR DD
Latitude/longitude source: VGPS QTopographic 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. 11 • GRILLING LOG
Top - Bottom
PANTRY - 464 N/A
Facility Name Facility ID# (if applicable)
2375 SOUTH 17TH STREET
Street Address
WILMINGTON
City or Town
THE PANTRY, INC
Contact Name
305 GREGSON DRIVE
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 [,�I
c. WATER LEVEL Below Top of Casing: 12.0
(Use "+" if Above Top of Casing)
FT.
•
•
•
•
•
•
•
•
•
•
•
•
0.0 / 20.0
2.0 in. .010 in. PVC
in. in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
•
: Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
/
FINE SILICA SAND
Formation Description
BROWN/TAN SAND
RECEIVED
JUJN
DwC,ROG
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
I DO HEREBY CERT
• 15A NCAC 2C, W
RECORD HAS B
•
•
SIGN
THAT THIS WELL WAS CONSTRUC ED IN ACCORDANCE WITH
CONSTRUCTION STANDARDS, AN P/' AT A COPY OF THIS
PROVIDE -ro TIsfl' ALL OWNE
04/30/12
E OF CERTIFIED WELL C % TRACTOR DATE
: JA ES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE VVEL,L