415155_Well Construction - GW1_20130812

WELL CONiSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
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):
For Internal Use ONLY
fi 'Y 5 5
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft,
ft.
15. OUTER CASLNG (for multi -cased wells) OR LINER (if I' bl )
FROM
TO
DIAMETER
Sch40
app PVC
THICKNESStea e
MATERIAL
0
ft.
75
ft.
4
in.
16. INNER CASLNG OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
Water Supple Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
D Irri gation
Non -Water Supply Well:
❑Monitorin g
❑AlunicipaI/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATE• RLAL
0
ft.
20 ft.
4
in.
.020
Sch40
PVC
ft.
ft.
in.
18. GROUT
FROM
0
ft.
TO
22
ft.
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
ft.
ft.
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothennal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Weil(s) Completed: 7/15/13
5a. Well Location:
Frank Davidson
❑Groundwater Remediation
❑Salinity Barrier
❑ Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
Facility/Owner Name Facility ID# (if applicable)
4615 Long Leaf Hills Drive, Wilmington, NC 28405
Physical Address, City, and Zip
New Hanover County R06111-006-007-000
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, 12.161 N 77, 53.170
6. Is (are) the well(s): OPermauent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ElNo
If this is a repair, fill out knonn well construction information and explain the nature of the
repair under #21 rentm•k's section or on the back ofthis •font.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one font.
9. Total well depth below land surface: 75 (ft.)
For multiple wells list all depths ifdifferent (example- 3G200' and 2®100 )
10. Static water level below top of casing: 25 (ft.)
if water level is above casing, use "+"
I I. Borehole diameter: 5 7/8 (in.)
12. Well construction met
hot --Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Air lift
13b. Disinfection t} pe: HTH Amount: 3g(.a� 1 0%
ft.
ft
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
50
ft.
75
ft.
Sand #2
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0
ft.
TO
8
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
Dark Brown medium sands
8
ft.
35
rt.
White medium sands
35
ft.
73
ft.
Tan medium to course sands
73
ft.
75
ft.
Gray clay to limestone rock at 75'
ft
ft.
ft
ft.
ft.
ft
21. REMARKS
'IJC a a ?n13
22. Certification:
Si
/4csI'/lc�cb
e of Certified'1Well Contractor)
Lie
(WATER QUALITY SECTiON
t114F1 t! i' 4'i ill J
it 'h `* Ibl(,1)Ni
7/15/13
Date
By signing this fo yin, I hereby certlfi: that the well(s) was (were) constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA 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 addit
above, also submit a copy of this
construction to the following:
Division of Water Quality, Uri
1636 Mail Service Ce
15,14
rotSttd'frlje1i2i 2OI1a
ss in 24a
of well
I Pro am,
Raleigh, NC 27699-1636
24c. For Water Sunrth & Irtiection 'RMi5L,,Ip_addition.lo-sending thg 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