410464_Well Construction - GW1_20130211

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North. Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
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#(if applicable)
SITE WELL ID #(if applicable) MW-3
3. WELL USE (Check One Box) Monitoring V Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 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 oValley &Olaf ❑Ridge ❑Other
LATITUDE 34 ° 42 ' 59.3800 "DMS OR
LONGITUDE 77 ° 19 ' 12.2000 " DMS OR
Latitudelongitude 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
DD
DD
Facility Name Facility 10# (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
City or Town
NC 27512
State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing: 13.0
(Use "+" if Above Top of Casing)
NO d
FT.
4163
1 2 4
`.t
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
Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 4o
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom Ft.
Top Bottom Ft.
Material
Et. PORTLAND BENTONITE
Material
PVC
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 20.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 4.0 Bottom 20.0 Ft. 20-40
Top Bottom Ft.
Material
FINE SILICA SAND
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 20.0
Formation Description
BROWN SILTY SAND
Fe
dsor� ?ofOp, ,
12. BEN ON TE SFAL FROM 3 0 TO 4 0 FEET����$�
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ApQPY OF THIS
RECOROII/yy BEEN PR)aVIDED TQSNE'7 0tE OW
11/2S/t2(•
IGNATURE OF CERD WELL CONTRACTOR CrAT 111
PRINTED IN ME OFF PERSON CONSTRUCTING THEVI(LL
� 9
Silbmtt Within 30 days of Comp'lefion to:q/vision of Water°Quality
1„617�Ma11 Service CenteriRaleigh P C 27699 161 Phofie [phone]
Form GW-'It5
Rev.-2/09