410459_Well Construction - GW1_20130211

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
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#Qf applicable)
SITE WELL ID #(if applicable) MW-8
3. WELL USE (Check One Box) Monitoring 1Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 11/06/12 - 11/07/12
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)
❑ ma Slope °Valley Flat ❑Ridge ❑Other
LATITUDE 34 ° 42 • 59.3800 " DMS OR
LONGITUDE 77 ° 19 ' 12.2000 " OMS OR
Latitudefongitude source: 3PS Dropographic 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
DD
DD
Mailing Address
CARY NC 27512
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 0 NO t J
c. WATER LEVEL Below Top. of Casing: 13.0 FT.
(Use "+" if Above Top of Casing)
Submit within 30 days Of completion to Division ofWaterQtiali
1617 Mad Service Center, Raleigh, NC 27699 161 Phone:.: [phone]
41r
d. TOP OF CASING IS 0.0 FT. Above Land Surface`
*Top of casing terminated aVor 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
7. CASING: Depth Diameter
Top 0.0 Bottom 5.0 Ft. 21NCH
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
Thickness/
Weight Material
SCH 40 PVC
Material
Ft. PORTLAND BENTONIIE
Ft.
Ft.
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 Material
Top 4.0 Bottom 20.0 FL 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 7.0
7.0 / 17.0
17.0 / 20.0
FINE SILICA SAND
Formation Description
BROWN CLAYEY SAND
GRAY SILTY/SAND
BROWN SILTY -SAND
12. REMARKS:
BFNTONITE SEAL FROM 3 0 TO 4 0 FEET
I DO HEREB/ ERTIFY ti �I(tF7111&
15A NCAC! • ; +NSy2UCTl
RECO'r�•r%�f.� OVI1IfSED TC
Sve
L WAS CO
3A)d0.4R]
RUCTED IN ACCORDANCE WITH
D THAT A COPY OF THIS
NER.
11/28/1,2
ATURE OF CERTIFIED WELL CONTRACTOR t DAATE ?.
JAMES HESS _ F
PRINTED NAME OF PERSON CONSTRUCTING THE WEL
c8 213 \\J
Form GW-7.b-
13ev:2/(59