407372_Well Construction - GW1_20120827

N
ON M ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Div
ision 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
City or Town 28443
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 ❑
Irrigation@" Other ❑ (list use)
DATE DRILLED 07/24/12
4. WELL LOCATION:
805 Midland Dr.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑ ValleyurFlat ❑ Ridge DOther
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
Robert Johnson
Contact Name
805 Midland Dr.
Mailing Address
City or Town
( 910 )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH. 65'
b...DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 25'
(Use "+" if Above Top of Casing)
State Zip Code
28412
State Zip Code
NO q/
FT.
•
: 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): 15 METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 1001
: g. WATER ZONES (depth):
Top Bottom Top
: Top Bottom Top
Top Bottom Top.
7. CASING: Depth
Top +1.5' Bottom 25'
Top Bottom
Diameter
Ft. 4"
Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0' Bottom 21' Ft. Bentonite Tremmie
Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight
sch40
Material
PVC
Method
9. SCREEN: Depth Diameter Slot Size Material
Top 25' Bottom 65' Ft. 4" in. .010 in
. PVC
Top Bottom Ft. in. in.
Top Bottom______— Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
▪ Top 21' Bottom 65' Ft. #2 Sand
i Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
▪ 0' / 6-
__5'____
• 65_/ 95'
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•
•
•
•
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•
•
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12. REMARKS
Formation Description
Sands / coarse quartz
Limestone clay (cave e 90')
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RD HAS BEEN PROVIDED TO TH -WELL OWNER.
_ 07/23/12
ATURE OF CERTIFIED WELL CO6IT CTOR
• � DATE
Donald H. Cummin s
PRINTED NAME OF PERSON C
• ONSTRUCTING THE WELL
Submit within 30day§ of completion
1617 Mail Service Center, Raleigh,
aver uii
919.) 807-6
Form GW-1 b
Rev. 2/09