410465_Well Construction - GW1_20130211

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4163
1. WELL CONTRACTOR:
MARK IRELAND
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# N/A
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(if applicable) DW-1
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery 0 Injection ❑
Irrigationp Other I7 (list use)
DATE DRILLED 11/05/12 - 11/06/12
4. WELL LOCATION:
2865 PINEY GREEN ROAD 28544
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: JACKSONVILLE COUNTY ONSLOW
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley pfFlat DRidge ❑Other
LATITUDE 34 ° 42 ' 59.3800 "DMS OR DD
LONGITUDE 77 ° 19 ' 12.2000 " DMS OR DD
Latitude/longitude source: VGPS ❑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 - 3126
N/A
Facility Name Facility ID# (if applicable)
2865 PINEY GREEN ROAD
Street Address
JACKSONVILLE NC 28544
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: 45.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO GI
c. WATER LEVEL Below Top of Casing: 23.0 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 Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 40.0 Ft. 2 INCH SCH ao PVC
Top 0.0 Bottom 34.0 Ft. 6 INCH SCH 40 PVC
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 35.0
Top 0.0 Bottom 34.0
Top Bottom
Material
F( PORTLAND BENTONITE
Ft. PORTIAND BENTONITE
Ft.
Method
SLURRY
SLURRY
9. SCREEN: Depth Diameter Slot Size
Top 40.0 Bottom 45.0 Ft. 2.0 in. .010 in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 38.0 Bottom 45.0
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
Material
PVC
Size Material
Ft. 20-40
FL
Ft.
FINE SILICA SAND
Formation Description
0.0 / 45.0 BROWN SILTY SAND
/ fh 7f /
/ ��� ",
a10
12. REMARKS:
BENTONITE SFAL FROM 35 0 TO 38 0 FFFT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
R7�QtiAS B pROVIDED ELL NER.
// /�'Q•/^Y{ /tI
SIGNATURE OF C IED WELL CONT} ACT,pR�
`711/28/12
DATE
p13
MARK IRELAND
PRINTED NAME OF PERSON CONSTRUVYINGT��N�LL
Submit within 30 daysi;of completion to Division of Water Civality Information Processing,
16'17 N(atl Service Center, Raleigh ,NC 27699-161 Phone [phone] " '
arm GW-1b
Rev. 2/09