414347_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Bobbie D Fower
Well Contractor Name
(NCWC) 2869-A
NC Well Contractor Certification Number
Mid -Atlantic Drilling, Inc.
RECEIVEDIDENRJDWQ
JUL 15 Z.013
Aquifer Protection Section
Company Name
2. Well Construction Permit #: N/A
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)
Olndustriai/Commercial
❑Irrigation
Non -Water Supply Well:
OMonitoring
❑ Municipal/Public
OResidential Water Supply (single)
OResidential Wafer Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
OExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 6/19/13
5a. Well Location:
Pemberton Drive - 310 N/A
❑Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID# MW-1
Facility/Owner Name Facility IDfi (if applicable)
310 Pemberton Drive Wilmington NC
Physical Address, City, and Zip
New Hanover N/A
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.190988 N 77'903579
6. Is (are) the well(s): OPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or E1No
If this is a repair, fill out known well construction information and explain the nature oldie
repair under s21 remarks section or on the hack of this form.
8. Number of wells constructed:
For multiple injection or non -water .supply wells ONLY with the sane construction, you con
submit one form.
1
9. Total well depth below land surface: 16 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@1(10')
10. Static water level below top of casing: 9 (ft.)
filmier level is above casing, use
I1. Borehole diameters 8 (in.)
12. Well construction method: 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.
rt.
ft.
rt.
15. OUTER CASING (for multi -eased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
2 in,
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
6 ft,
2 in.
sch 40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
6 ft•
16 ft•
2 in,
0.01
sch 40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EIAPIACEMENT METHOD & AMOUNT
2 ft.
4 ft.
bentonite
pour
0 ft.
1 ft•
concrete
pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft.
16 ft-
#2 torpedo sand
pour
1 ft
2 ft•
natural pack
pour
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
it.
ft.
ft.
ft.
ft.
ft.
R.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Concrete pad/ w flush mount man hole cover
22. Certification:
t=at&
07/01/2013
SigPre of Certified Well Contractor Dale
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 1SA 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 hack 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 fonn 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 Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sendino the form to
the address(es) above. also submit o $ t F Sf t n • D ays of
completion of well construction to I r a ea , e of th county
where constructed.
JUL 222013
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Qui sed Ian. 2013