407373_Well Construction - GW1_20120827

N.NRESIDENTIAL WELL CONSTRUCTION
TR N RLC®R
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, RC.
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: : 7. CASING: Depth
WELL CONSTRUCTION PERMIT# : Top +1.5' Bottom 130' Ft. 4"
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationlj Other ❑ (list use)
DATE DRILLED 07/18/12
4. WELL LOCATION:
200 Snua Harbour Dr.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope ❑ Valley ❑ 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
Kevin O'Brien
Contact Name
200 Snua Harbour.Dr
Mailing Address
Wilminaton
City or Town
( 910 ) 262-1961
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 145'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 25'
(Use "+" if Above Top of Casing)
State Zip Code
NC 28405
State Zip Code
YES ❑ NO Ei/
FT.
d. TOP OF CASING 1S 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 1 0 fQ
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
Diameter Weight Material
sch40 PVC
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0' Bottom 22'
Material
Ft. Grout
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth.
Method
Tremmie
Diameter Slot Size Material
Top 130' Bottom 145' Ft. 4" in. .020 in. PVC
Top Bottom
Top Bottom
Ft. in. in.
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 125' Bottom 145'
Top
: Top
Bottom
Bottom
: 11. DRILLING LOG
Top Bottom
Size
Ft. #2
Ft.
Ft.
Material
Sand
Formation Description
0' / 52' Clay / sand
: 52' / 90' Limestone
90' / 130' Clay
130' / 145' Sandstone (Cave 150')
•
rrA
12. REMARKS:
t
I DO HEREBY CERTIFY THAT THIS WELL WAS CONC,TEDTACCOR CE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ECORD HAS BEEN PIROVID D T THE WELL OWNER.
A
F ---� 07/18/12
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
•
LJ
Donald H a Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Submit within 30 days of completion tog Division of Water uality
1617 Mail Service Center, Raleigh, NC 2Th99 16/, Phone [phone]
nfor atton. Processing,
Form GW-lb
Rev. 2/09