407374_Well Construction - GW1_20120827

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412-A
1. WELL CONTRACTOR:
Donald H. Cummings
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationtj Other ❑ (list use)
DATE DRILLED 07/19/12
4. WELL LOCATION:
7101 Lona Boat Circle : Top 135' Bottom 150' Ft. 4" in. .020 in. PVC
Top Bottom Ft. in. in.
CITY: Wilmington COUNTY New Han. ; Top • Bottom Ft. in. in.
•
•
•
.
4 n
d. TOP OF CASING IS 1.5' FT. Above Land Surface"
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 60
METHOD OF TEST Airlift
f. DISINFECTION: Type HTH
Amount
3q(.10%
: g. WATER ZONES (depth):
▪ Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top +1.5' Bottom 135' Ft. 4" sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0' Bottom 20' Ft. Grout Tremmie
Top Bottom Ft.
Top Bottom Ft.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley ❑ Flat ❑ Ridge ❑ Other
LATITUDE 34 "DMS OR DD
LONGITUDE 77 " DMS OR DD
Latitude/longitude source: VGPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Karen Hollinasworth
Contact Name
7101 Lona Boat Circle
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
( 910 ) 799-0196
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 150'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 23'
(Use "+" if Above Top of Casing)
YES ❑ NO q/
FT.
▪ 9. SCREEN: Depth
: 10. SAND/GRAVEL PACK:
Depth
Top 125' Bottom 145'
Top Bottom
: Top Bottom
: • 11. DRILLING LOG
Top Bottom
0' / 52'
52' / 90'
90' / 135'
135' / 150'
12. REMARKS:
Diameter Slot Size Material
Ft.
Ft.
Ft.
Size Material
#2 Sand
Formation Description
Clay / sand
Limestone
Clay
Sandstone (Cave 5 150')
_ i,• i a
U(��2
E.:
E •.^
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ORD HAS BEEN PROVIpED T9THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL
_ 07/19/12
TRACTOR DATE
Donald H. Cummings
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion to Division of
161.E Mail Service Center, Raleigh, C 27699.1hone
Form GW-1 b
Rev. 2/09