414926_Well Construction - GW1_20130805

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
VINCE FEDERLE
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Weil Construction Permit #:
List all applicable well construction permits (Le. County, State, Variance, etc.)
3. Well Use (check well 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
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatin Cooling Return)
4. Date Wells) Completed: 07/02/13
5a. Well Location:
$2.50 CLEANERS
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
Well IBM
MW-2R
Facility ID# (if applicable)
810 SOUTH COLLEGE ROAD WILMINGTON 28403
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 Iat/long is sufficient)
34° 13' 18.13" N 77° 53' 03.70" W • l ¢(3,6
Signature of Certified Well Contractor
:: 14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft
;15. OUTER CASING (for multi-casedwvells) OR LINER(if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16.,INTIERtCASING OR TUBING (geothermal ;closed -loop) ,
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
2.0 ft
1.0 in'
SCH 40
PVC
ft.
ft.
in.
12 SCREEN '
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2.0 ft•
10.0 ft•
1.0 in'
.010
SCH 40
PVC
ft.
ft.
in.
18.'GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
1.0 ft.
PORTLANOBENTON1TE
SLURRY
ft
ft
ft.
ft.
19 SANINGRAvELPACK'(ifapplicabie)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1.5 ft•
10.0 it
20-40
FINE SILICA SAND
ft.
ft.
>20 DitII.LWGLOG
(atfai•L additional 'slieets:if necessary) " ,
FROM
TO
DESCRIPTION (color, hardness, soilfrock type, grain size, etc.)
0.0 ft'
1.0 ft.
CONCRETE/GRAVEL
1.0 fL
10.0 fL
SAND
ft
ft
fL
ft
ft
ft
ft.
ft.
i _r
ft.
ft.
.
}.21: REMARKS : .. .... ... . . . .....
BENTONITE SEAL FROM 1.0 TO 1.5 FEET
6. Is (are) the well(s): t2lPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or BNo
If this is a repair. fill out known well construction information and explain the nature of the
repair under #21 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.
9. Total well depth below land surface: 10• 0 (ft)
For multiple wells list all depths II -different ferent (example- 3@200' and 2@l00)
10. Static water level below top of casing: 4'0 (ft)
If water level is above casing, use "+"
11. Borehole diameter: 2 1/8 (in.)
12. Well construction method: DPT RODS
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. C tification:
07/09/13
Date
By signing this form, 1 hereby certt& that the well(s) was (were) constructed in accordance
with ISO 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 followin
Unit,
e Center,rte�`Raleigh, NC 276 17
24b. For Injection Wells: I ; addititi lQ sOn5n2813orm o he address in 24a
above, also submit a copy o this form within 30 days o mpletion of well
construction to the following �?
Division of Water Quality, Underground Injection ontrol Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Simply & Injection Wells: In addition to sending the 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.
Division of Wat
1617 Mail S
GEIVE
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013