414799_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A - 2345
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):
•
Water Supply Well:
DAgricultural
°Geothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
❑Irrigation
❑Municipal/Pub]ic
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
°Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 06/04/13 Well ID#
5a. Well Location:
RMR - 6265
IW-4
Facility/Owner Name Facility IDN (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' 27.41" N 77° 55' 14.46"
6. Is (are) the well(s): °Permanent or ❑Temporary
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair. fill out known well construction information and explain the nature of the
repair under 1121 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 same construction. you can
submit one form.
9. Total well depth below land surface: 25'0 (ft.)
For multiple wells list all depths if different (example- 3 a(�1 00' and 2 rr 100')
10. Static water level below top of casing: 10.0 (ft)
If water level is above casing, use "+"
11. Borehole diameter: 10.0 (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:
For Internal Use ONLY:
-4 r1 r-;
.. t
:14.,WATER ZONES . ... _;
FROM
TO
DESCRIPTION
ft.
ft
ft
ft.
t.1513UTERCASING{foYnoulir=casedwells)'ORLINER(ifappresble)': .. . .
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
1dANPIERCASING
OWEUBIL`tG',(gikheritial'closed3oop)r
2 r
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
5.0 ft.
4.0 in'
SCH 40
PVC
ft.
ft.
in.
17i;t01.E$N
$'i ,
'i:At;h1. 1f.4t ? .s �34ers:K ; r 't i Fry' l
FROM
TO
DIAMETER '
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft
25.0 ft
4.0 in'
.020
SCH 40
PVC
ft.
ft.
in.
Y1$.'GROUT
e , .. _.
T ._.1e°fr."- 7.7g'1 0i
;`„ t ;
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft
3,0 ft-
P°RMNDBENroNRE
SLURRY
ft
ft.
ft
ft.
(yI4 S1NDlGRAVELYACJC`(rLapplicable)
.
c..
^i ' ,� s;.+ .a..,,,., ,.t
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft
25.0 fe'
20-40
FINE SILICA SAND
ft.
ft
20.:DRILLING:I OG'(iitaciiadditi'oal sheets: riiiC' sary) -
FROM
TO
DESCRIPTION (color, hardness, soillroek type, grain sine, etc.)
0.0 ft
5.0 fL
GRAY CLAY
5.0 ft
13.0 ft
LIGHT GRAY CLAY
13.0 ft
19.0 ft
TAN SANDY CLAY
19.0 ft
25.0 ft
GOLD SAND
ft
ft
77 (�
ft.
ft
-i}1- -i.'nf". (_L1.
ft
it
i / l �IJAI lY. FT TION
-2P:REEtIIAIIIcs. ...... ?. '' 'tp g4y40ht-Pl sTf`tiNi1
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
22. Certification:
Signature of Certified Well Contractor
06/27/13
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA 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 Injection 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, Underg
1636 Mail Service Center,
24c. For Water Su ' 1 & Injection We
the address(es) above, also submit one
completion of well construction to the
where constructed.
•
� gCa'fres
f i
In acMi!ibn tq sending the form to
o.y o) 4iirforrrt'within 30 days of
unty health department of the cdunty
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Jan. 2013