412344_Well Construction - GW1_20130313

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WELL CONSTRUCTION RECORD
This tom 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 #: NA
List all applicable well construction permits (i.e. Connor, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commeroial
❑Irrigation
Non -Water Supply Well:
°Monitoring
o Municipal/Public
o Residential Water Supply (single)
o Residential Water Supply (shared)
o Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
❑ Groundwater Ram ediation
❑ Salinity Ranier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
o Other (explain under #21 Remarks)
For Internal Use ONLY:
41'34'
14. WATER ZONES
FROM
TO
DESCRIPTION
7
18
ft
Surficial
ft
15. OUTER CASING (for m
FROM
+2 ft
TO
3
Wti-cased wells OR LINER(8ap licable)
1
DIAMETER THICKNESS MATERIAL
2 i" SCH-40 PV
C
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
in
ft
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
3 fL
18 D•
2
in.
0.010
SCH-40
PVC
fL
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
fL
1.5 rL
Bentonite
Poured
ft
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1.5 it
18
ft
Coarse Sand
Poured
ft.
20. DRILLING LOG (atta h additional sheets If necessary)
FROM
ft.
TO
fL
DESCRIPTION (color, hardness, soll/rock type, grab site, etc.)
See attahced.
4. Date Wen(s) Completed: 2/11/13
5a. Well Location:
Hampstead Town Center
Well ID# MW-2
Facility/Owner Name Facility ID# (if applicable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and Zip
Pender
3293-86-8315-0000
County Parcel IdcntificationNo. (PIN)
5b. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
24 deg. 23' 29.21" N 77 deg. 40' 39.74"
6. Is (are) the well(s): °Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or BNo
If this is a repair, fill out !mown well construction information and explain the nature of the
repair under #21 remarks section or an the back of this form.
8. Nuinber of wells constructed: 4
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: 18
(ft)
For multiple wells list all depths (different (example- 3@200'and 2@100)
10. Static water level below top of casing: 8.41 (ft.)
If water level is above casing, use "4"
11. Borehole diameter: 8
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft.
ft.
ft
ft.
ft
rt
fL
ft.
ft
fL
MAR 1 3 2013
21. REMARKS
WATER f uAi ITV SECT IVN
INFORMATION PROCESSING UNIT
22. Certification:
�n��^�_
Sim/aims of Certified V/ell Contractornt-'
Date
By signing this form hereby cert& that the well(s) tons (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA 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
246. For Iniection Wells: In addition to sending the form to the il44 s in 24a
above, also submit a copy of this form, yithi€tv3U)IV3 kdt�op mletionglpf well
construction to the following: i �kd y 4j
1l
Division of Water Quality, Undeigboun Q�gtin a rogra
1636 Mail Service Center„RalfiN /CZ7699� it f'
1, form
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one,ggpy ofihis-form-withiirlreraya of
completion of well construction to the county health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environment a d Natural Resources -Division of Water Quality Revised Jan. 2013

HAMPSTEAD TOWN CENTER
17270 HIGHWAY 17
HAMPSTEAD, NORTH CAROLINA
MW-2
Drilled by : M. Sage
Logged by: J. Zuncich
Date: 02/11/13
Depth
(ft)
Description
Water
Content
Blow
Count
2 - 4
Tan -brown mottled orange, silty to very fine grained sand
with organic material and root matter. No odors.
Low
Grab
5 - 7
Medium gray, slightly clayey sand, grading to a brown-
orange, silty, very fine grained sand. No odor.
Low to
Moderate
HP
10 - 12
Tan -orange, very fine grained sand with thin lenses at 10.2' -
10.3'. No odor.
High
HP
15 - 17
Tan -orange very fine grained sand with thin lenses at 10.2' -
High
HP
10.3' changing to greenish -gray, slightly clayey sand. No
odor.
HP - Hydraulic Push
`Cn[ Fug.-lalY k
MAR 18 2013