414348_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For !menial Use ONLY:
1. Well Contractor Information:
Bobbie D Fower
RECEIVED!DENRIDWQ
Well Contractor Name
(NCWC) 2869-A
NC Well Contractor Certification Number
JUL 15 (LID
Aquifer Protection Section
Mid -Atlantic Drilling, Inc.
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check welt use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
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
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4, Date Well(s) Completed: 6/19/13
5a: Well Location:
Johnston Drive - 313
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #2I Remarks)
Well iD# MW-1
N/A
Facility/Owner Name Facility ID# (if applicable)
313 Johnston 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 lallong is sufficient)
34.190282 N 77,903683
6. Is (are) the well(s): OPermanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or l7No
If this is a repair, fill our known well construction information and explain the nature oldie
repair under e21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or Iron -water. supply wells OA'LJ' with the some construction, you can
submit one form.
1
9, Total well depth below land surface:
For multiple wells list all depths if different (example- 3C200 • and 2@a.100')
16
(ft.)
10. Static water level below top of casing: 8 (ft.)
If water level is above rasing, use " "
11. Borehole diameter: 8
12. Well construction method:
(in.)
auger above, also submit a copy of this form wit
construction to the following::<
(i.e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
I5. OUTER CASING (for multi -cased 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 fL
6 ft-
2 in.
sch 40
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
6 ft.
16 f'•
2 in.
0.01
sch 40
pvc
ft.
rt.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2 ft.
4 f'•
bentonite
pour
0 ft.
1 ft•
concrete
pour
f4
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft•
16 ft-
#2 torpedo sand
pour
1 fl•
2 f'•
natural pack
pour
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain sae, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
et.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Concrete pad/ w flush mount man hole cover
22. Certification:
f,
Signature of Certified Well Contractor
07/01/2013
Date
By .signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
srirh 15A NCAC.' 02C .0100 or 1SA 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
Iction of well
Division of Water Quali +nder r ndP ry c ' oat ;1l 7 rogram,
1636 Mail Servic . entieith stljP 9-1
24c. For Water Su • Iv & In
the addresses) above. also su
completion of well construction
where constructed.
n Wells: In addition to sendi `,,'the form to
one copy of 30 days of
tit comity health department of the county
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised Jan. 2013