406387_Well Construction - GW1_20120822

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
( 704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) RW-2
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery WInjection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 05/31/12
4. WELL LOCATION:
2375 SOUTH 17TH STREET 28403
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WILMINGTON
COUNTY NEW HANOVER
TOPOGRAPHIC 1 LAND SETTING: •(check appropriate box)
❑ Slope [Valley EciFlat ❑ Ridge ❑ Other
LATITUDE 34 ° 19 ' 93.3700 " DMS OR
LONGITUDE 77 ° 92 ' 18.8300 " DMS OR
Latitude/longitude source: UIGPS ❑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 - 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 (�I
c. WATER LEVEL Below Top of Casing: 10.0 FT.
(Use "+" if Above Top of Casing)
mat •5ervrce center, Bale .gt
sion Water
1J)
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. 4 INCH SCH 40 PVC
Top Bottom Ft.
: Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 3.0
Ft. PORTLAND BENTONITE
Top Bottom Ft.
: Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft. 4.0 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 FINE SILICA SAND
: Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
• 0.0 / 1.0 ASPHALT/GRAVEL
1.0 / 20.0 GRAY SILTY SAND
/
•
12. REMARKS: DI r�OC ss
• BENTONITE SEAL FROM 3.0 TD 4.0 FEET
I LI I
4Y
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCA C, WELL CONSTRU TION ST DARDS, AND THAT A COPY OF THIS
REC R HAS BEEN P of D 0 THE L O NER. .
•• 06/ 18/ 12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
: VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTI';NG`THE :WELL-
uah
orrnation Processi:
o v-b
2
Rev. 2/09