414921_Well Construction - GW1_20130805

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK IRELAND
Well Contractor Name
A - 4163
NC Well Contractor Certification Nutnber
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):
Water Supply Well:
❑Agricultural
DGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
[Monitoring
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 07/15/13
5a. Well Location:
RMR - 6265
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
Well ID#
IW-2
Facility/Owner Name Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD 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° 17' 26.97" N 77° 55' 14.80"
6. Is (are) the well(s): [Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or t1No
If this is a repair, fill out known 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 -nester supply wells ONLY with the same construction, you can
submit one form.
25.0
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 15•0 (ft)
If water level is above casing, use "+"
10.0
11. Borehole diameter:
12. Well construction method:
(in.)
AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if sp . icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING" OR TUBING(geothermal closed -loop)"
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft•
5.0 ft.
4.0 in'
SCH 40
PVC
ft.
ft.
in.
:17d SCREEN .: _,,, ,
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft•
25.0 ft•
4.0 'n'
.020
SCH 40
PVC
ft.
ft.
in.
.18. GROUT.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
3.0 ft
PONMNDBENTONITE
SLURRY
ft
ft.
ft.
ft.
19. SAND/GRAVEL PACK :(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft'
25.0 IL
20-40
FINE SILICA SAND
ft.
ft.
10. DRILLING:LOG (attach additional sheets if necessary) =t:
FROM
TO
DESCRIPTION (color, hardness, soiUrock type, grain size, etc)
0.0 ft
5.0 ft.
SANDY CLAY
5.0 ft•
25.0 ft•
SAND
ft.
ft.
ft
ft
ft.
ft.
ft.
ft.
1
ft.
ft
U.:REMARKS ;'
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
tifica ro
dt>✓
07/17/13
Signature of Certified Well Contractor Date
By .signing this form. I hereby certffy that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or 114 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 Servi
''. r Ra�lei ly NC 27699-1617
n Wells: In •2 � t 1T tL- t>
24b. For Injection
above, also submit a copy o
construction to the following:
address in 24a
s fowlthin 30 days of c�rtletion of well
Rtiti 05 202
sf irtg Dr
E
Division of Water Quali ,' nderground Injection Con Program,
1636 Mail ServiiR enter, Raleigh, NC 27699- 6
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form 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 Jan. 2013