412345_Well Construction - GW1_20130318

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531
NC Well Contractor Certification Number
'Applied Resource Management, PC
Company Name
2. Well Construction Permit ft:NA
List all applicable well construction permits #.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgrioultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/C ommercial
❑Irrigation
Non -Water Supply Well:
O Monitoring
❑Munioipal/Public
O Residential Water Supply (single)
O Residentiai Water Supply (shared)
O Recovery
For Internal Use ONLY:
41.234
Injection Well:
OAquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
OExperimental Teobnology
❑Geothermal (Closed Loop)
O Geothennal (Heating/Cooling Retum)
4. Date Wen(s) Completed: 2/11/13
5a. Well Location:
Hampstead Town Center
OGroundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
OOther (explain under #21 Remarks)
Well ID# MW-1
Facility/Owner Name Facility D# (if applicable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and hip
Pender
3293-86-8315-0000
County Parcel IdentificationNo. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
24 deg. 23' 30.56" N 77 deg. 40' 35.12"
6. Is (are) the well(s): oPermanent or OTemporary
7. Is this a repair to an existing well: OYes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
4
9. Total well depth below land surface: 17
For multiple wells list all depths if &rent (example- 3((200'and 2@100)
10. Static water level below top of casing: 7.48
If water level is above casing. use "+"
11. Borehole diameter: 8 Cn-)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
(R)
(ft.)
14. WATER ZONES
FROM
7
TO
DESCRIPTION
ft.
17
ft
Surficial
ft.
it.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
THICKNESS 11 MATERIAL
FROM
+3 ft
TO
2
ft.
DIAMETER
2
in.
SCH-40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
THICKNESS
FROM
TO
ft.
DIAMETER
in.
MATERIAL
ft.
fL
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 rl
17
2
in
0.010
SCH-40
PVC
ft.
ft.
In.
18. GROUT
FROM
0
TO
fr.
MATERIAL
Bentonite
EMPLACEMENT METHOD & AMOUNT
Poured
R
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
1
TO
MATERIAL
EMPLACEMENT METHOD
17
ft.
Coarse Sand
Poured
ft.
ft.
20. DRILLING LOG (atta h additional sheets if necessary)
DESCRIPTION (color, hardness, soil/rock type, grabs size, etc.)
FROM
IL
TO
FL
a
See attahced.
ft.
fL
ft.
it.
ft.
ft.
ft
it.
MAR 18 2013
21. REMARKS
OH 1 3 �7413
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. CerllRcation:
fled Well Contractor
Signature of Ce
WATER QUALITY SECTION
INFORPAATION FROCCCCING UNIT
Date
By signing this form, I hereby cert fy that the well(s) nos (were) constructed in accordance
with ISA 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 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 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.
Form GW-1
North Carolina Department of Environment and Natural Resources -Division of Water Quality
Revised Ian. 2013

•
HAMPSTEAD TOWN CENTER
17270 HIGHWAY 17
HAMPSTEAD, NORTH CAROLINA
MW-1
Drilled by : M. Sage
Logged by: J. Zuncich
Date: 02/11/13
Depth
(ft)
Description
Water
Content
Blow
Count
2 - 4
Brown -orange to tan, very fine grained sand with root matter.
No odors.
Low
Grab
5 - 7
Tan to light brown mottled orange, silty to very fine grained
sand with minor wood fragments. No odor.
Moderate
HP
10 - 12
Tan to light brown mottled orange, silty to very fine grained
sand with minor wood fragments. No odor.
High
HP
15 - 17
Greenish -gray, slightly clayey, silty fine grained sand. No
odor.
High
HP
HP - Hydraulic Push
MAR 18 2013