414764_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY BURR
Well Contractor Name
A - 3098
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance. etc)
3. Well Use (check well use):
WM0800989
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Ind ustrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
17Monitoring DRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
DGroundwater Remed iation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
DOther (explain under #2I Remarks)
4. Date Well(s) Completed: 05/22/13
5a. Well Location:
HORTON IRON & METAL
Well ID#
MW-11
Facility/Owner Name Facility IDII (if applicable)
2216 US HIGHWAY 421 WILMINGTON 28401
Physical Address, City, and Zip
NEW HANOVER
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° 15' 57.01" N 77° 57' 16.94"
6. Is (are) the well(s): ❑Permanent or OTemporary
7. Is this a repair to an existing well: DYes or EINo
If this is a repair, fill our known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the sale construction, you can
submit one form.
9. Total well depth below land surface: 14.0 (ft.)
1
For multiple wells list all depths ii difj'erenl (example- 3@200' and 2 r@100')
10. Static water level below top of casing: 4'0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8.0 (in.)
AUGER
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
fe.
ft.
:.15. OUTER CASING (for multi -cased wells) OR LIiVSR.„(fop icable): . .
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
.16'INNER.CASING OR TUBING (geothermal dosed -loop);'
=
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
4.0 ft.
2.0 in'
SCH 40
PVC
rt.
ft.
in.
17:-SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
4.0 ft.
14.0 ft,
2.0 in-
.010
SCH 40
PVC
ft.
ft.
in.
18:'''GROU1l . ," , ..
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
1.0 ft.
P°R"j"8 fTOnnE
SLURRY
ft.
ft.
ft.
ft.
'19 'SANDJGRAVELPAGK,(if
applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft.
14.0 ft.
20-40
FINE SILICA SAND
ft.
fr.
:2d: DRILLING LOG`(attacli additional sheetsifn'ecessary) -.
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc-)
0.0 ft'
1.0 ft.
BLACK TOPSOIL
1.0 ft.
9.0 ft-
TAN SAND
9.0 ft-
14.0 ft.
YELLOW SAND
fc
ft.
ft
ft.
i
t <t, (. ..
ft.
ft.
ft.
ft.
,i,,$.a". '.CO( �F SIN ] t.INI1
;,21.: REMARKS ='= i-
BENTONITE SEAL FROM 1.0 TO 3.0 FEET
22. Certification:
EI[/v 06/05/13
Si v e" ofCe , Well Contractor Date
signing this form, 1 hereby certt& that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well 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 Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Cent ) Raleigh NC 27699-1636
24c. For Water Su 1 & Injection w 1 1LIt� "�gi to
the address(es) above, also submit o opy f is form within 30 s of
completion of well construction to th unt t this
lartpfppt3of e,. ounty
where constructed. 5s ttCCUUii�l
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Qualit61/. Revised Jan. 2013