409968_Well Construction - GW1_20121217

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2579
1. WELL CONTRACTOR:
DANNY SUMMERS
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# N/A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-12
NC
State
28625
Zip Code
3. WELL USE (Check One Box) Monitoring C( Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 10/30/12
4. WELL LOCATION:
2305 SOUTH COLLEGE ROAD 28412
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope [Walley wrFlat 0 Ridge ❑ Other
LATITUDE 34 ° 12 ' 2.6000 " DMS OR
LONGITUDE 77 ° 53 ' 15.6400 " DMS OR
Latitude/longitude source: LIGPS ['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.)
DD
DD
PANTRY - 938 N/A
Facility Name Facility ID# (if applicable)
2305 SOUTH COLLEGE ROAD
Street Address
WILMINGTON NC 28412
City or Town State Zip Code
THE PANTRY, INC
Contact Name
PO BOX 8019
Mailing Address
CARY NC 27512
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
•
•
•
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
Top Bottom Top
: 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.
Bottom
Bottom
: 8. GROUT: Depth Material
Top 0.0 Bottom 3.0
Top Bottom Ft.
: Top Bottom Ft.
Ft. PORTLAND BENTONITE
9. SCREEN: Depth
Top 5.0 Bottom 25.0 Ft.
: Top Bottom
= Top Bottom Ft. in. in.
Method
SLURRY
Diameter Slot Size Material
2.0 in. .010 in. PVC
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
: Top 4.0 Bottom 25.0
: Top
Top
11. DRILLING LOG
: Top Bottom
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
0.0 / 25.0
Size Material
Ft. 20-40
Bottom Ft.
Bottom Ft.
/
I
/
/
FINE SILICA SAND
Formation Description
WHITEITAN SAND
• i:� R. s" t'�:�Qiis i...�rt^-'xr _�'•.". 1=,,� �`Z'�`. ?,�e113�`r.:a'
iz:. 17
12. REMARKS:
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET E f `'
CONSTRUCTED IN ACCORDANCE WITH
ARDS, AND THAT A COPY OF THIS
L OWNER.
NOji
I DO HEREBY CERTIFY THAT THIS WELL
• 15A NCAC 2C, WELL Cs STRUCTION ST
REDHASBEENPI IDED TO THE
•
20
11/15/12
12
ERTIFIED WELL CONTRACTOR DATE
: DANNY SUMMERS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•'1mit•:-wrthin 30 da. •• s of : com letio:n -to: �Divis•io
•p•n of Water £uafr
r Service Center, Ralet
� i ✓
orma ion
rocessing
Form GW-1 b
Rev. 2/09