414923_Well Construction - GW1_20130805

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
MARK IRELAND
Well Contractor Name
A - 4163
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:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Ir igation
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
°Geothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 07/15/13
5a. Well Location:
RMR - 6265
Well ID#
IW-5
Facility/Owner Name Facility IDIt (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 lationg is sufficient)
34° 17' 26.86" N
77° 55' 15.06"
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 /121 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water 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 ifdifferent (example- 3 rt 00'and 2@100')
100')
10. Static water level below top of casing: 15.0 (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;
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if app 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.
5.0 ft'
4.0 in•
SCH 40
PVC
ft
ft.
in.
47. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft
25.0 ft
4.0 in'
.020
SCH 40
PVC
ft.
ft.
in.
':' 18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft
3.0 ft
pomiANonensOwrn
SLURRY
ft
ft.
ft.
ft.
_,19i SAND/GRAVEL. PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft
25.0 ft-
20-40
FINE SILICA SAND
ft,
ft.
20: DRiLLING
LOG attach additional sheets if oecessa
FROM
TO
DESCRIPTION (color, hardness, soWroek 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
ft.
ft.
•
l'I`I.
;. UPI)
:=21 iREMARES.:::.
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
22. Certification:
07/17/13
Signature of Certified Well Contractor ` Date
By signing this form, I hereby certt& that the well(s) was (were) constructed in accordance
with I5A 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 Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy l * �s of completion of well
construction to the followin
Division of Water Qu , Ur s oti94,1nlec io C ' +ol Program,
1636 Mail Se e C ii R ee11h��]]' Dv11h 769'- 6
24c. For Water Supply &)?It�''dction Wells: In addition to s , ing the form to
the address(es) above, also MID ne co of this fornt' 'ithin 30 days of
completion of well construction to the county h IUi'ifepartment of the county
where constructed.
Fonn GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013