415152_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald H. Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: NIA
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
415152
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
rt.
15. OUTER CASING (for multi -cased pelts) OR LINER Of apcae 1' bl )
FROM
0
ft
TO
60
rt.
DIAMETER
6
in.
p r
ARTERIAL
Sch40 PVC
THICKNESS
T
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0
ft.
160 n•
4
in.
Sch40
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
BIrrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal'Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothennal (Closed Loop)
❑Geotltennal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Bather
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
25
ft.
Grout
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
fi.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0
ft.
TO
43
ft.
DESCRIPTION (color, hardness. soil/rock type, grain size. etc.)
Sands and clays
4. Date Well(s) Completed: 7/9/13
5a. Well Location:
Tony Ivey Custom Homes
Facility/Owner Name
Well ID#
Facility ID# (if applicable)
1532 Radian Road, Wilmington, NC 28405
Physical Address, City, and Zip
New Hanover County
R05118-001-034-000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34, 14.157 N 77, 48.775
W
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or ENo
If this is a repair, ill out knolin well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supple welts ONLY with due saute construction, you can
submit one form.
9. Total well depth below land surface: 185
For multiple wells list all depths ifd(jferenr (example- 3i t20(1 and 2@100)
10. Static water level below top of casing: 80 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 5 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft.)
43
ft.
115 ft.
Limestone
115 ft.
155 ft.
Clay and mud rock
155 ft.
185 n•
Sandstone
ft.
ft.
ft.
ft.
AUG 1 2013
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Air lift
13b. Disinfection tape: HTH .amount: 3qp 10%
ft.
21. REMARKS
ft.
WATER QuALIIY SECTION
ilait�f)1?ftaa1'irlh: °RC(,FSSINGUitNl
Void at 46', set 50' of 6" casing.
22. Certification:
Sigit thaf€ ertifted Well Contractor
7/9/13
Date
By signing this form, 1 hereby cer•tif}' that the well(s) uos 6 •e) consn•ncted in accordance
with 1 SA NCAC 02C .0100 or I SA NCAC 02C .0200 it e11 Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All V4'elis: Submit this form within 30 days of or of well
construction to the following:
Division of Water Qu
1617 Mail Service
24b. For Infection Wells: In ad
above, also submit a copy of thi
construction to the following:
ECEPV
, Inf rmation Processing Ur 'ti
er, Aubh,p22 hi 0617
n to sending the form to the Tess in 24a
ip within 30 days of comp etion of well
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Tian. 2013