405678_Well Construction - GW1_20120612

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
( 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
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 NC 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) MW-12
3. WELL USE (Check One Box) Monitoring ti Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 04/26/12
4. WELL LOCATION: : 9. SCREEN: Depth Diameter
p Slot Size Material
2375 SOUTH 17TH STREET 28403 Top 5.0 Bottom 20.0 Ft. 2.0
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) in. .010 in. PVC
CITY: WILMINGTON COUNTY NEW HANOVER
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Q Slope ❑ Valley ifFlat 0 Ridge ❑ Other
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.
LATITUDE 34 ° 11 • 58.0000 ~DMS OR DD
LONGITUDE 77 ° 55 20.9400 " DMS OR DD
Latitude/longitude source: (BPS ❑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.)
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 [1.
c. WATER LEVEL Below Top of Casing: 12.0 FT.
(Use "+" if Above Top of Casing)
: Top
Top Bottom Ft. in. in.
Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 4.0 Bottom 20.0 Ft. 20-40
: Top • Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
•
0.0 / 20.0
FINE SILICA SAND
Formation Description
BROWN/TAN SAND
j
12. REMARKS:
: BENTONITE SEAL FROM 3.0 TO 4.0 FEET
I DO HEREBY CER ' THAT THIS WELL WAS CONSTR
• 15A NCAC 2C, W. CONSTRDARDS, A
RECORD HAS :; " i • rED
Ar
THE
• SIGN
ED IN ACCORDANCE WITH
HAT A COPY OF THIS
•
E OF CERTIFIED WELL CONTRACTOR
04/30/12
DATE
: JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
JUN 182012
Form GW-1 b
Rev. 2/09