406365_Well Construction - GW1_20120820

NON
ESIDENTIAL WELL CONSTRUCTION RECORD
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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 0 Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation d Other 0 (list use)
DATE DRILLED 05/21/12
4. WELL LOCATION:
92 Pelican Point Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ Valley ❑Flat ❑Ridge ❑Other
LATITUDE 34 ° 9 14.6400 •" DMS OR
LONGITUDE 77 ° 51 ' 34.1500 " DMS OR
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.)
DD
DD
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
George Escaravaae
Contact Name
92 Pelican Point Rd
Mailing Address
Wilminaton NC 28409
City or Town State Zip Code
( 910 ) 465-5711
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 140'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ICI
c. WATER LEVEL Below Top of Casing: 12'
(Use "+" if Above Top of Casing)
FT.
Submit within 30 days of completion to: Division of WaterQuality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone (9 - 807-6300
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: 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): 80 METHOD OF TEST Airlift
f. DISINFECTION: Type HTH
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
:7. CASING: Depth Diameter
Top +1.5 Bottom 120' Ft. 4"
: Top 0' Bottom 80' Ft. 6"
Top Bottom Ft.
8. GROUT: Depth Material
Top 0' Bottom 80' Ft. Grout
Amount 3pl 10 %,
Bottom
Bottom
Bottom
: Top 0' Bottom 26' Ft. Grout
Top 112' Bottom 116' Ft. Bentonite
Thickness/
Weight Material
sch40 PVC
sch40 PVC
Method
Pressure
Tremmie
Tremmie
9. SCREEN: Depth Diameter Slot Size Material
Top 120' Bottom 140' Ft. 2" in. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 116' Bottom
Size Material
140' Ft. #2 Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0 /40'
Formation Description
Sand to fine to coarse
40' / 60' Clay
: 60' / 110' Limestone
: 110' / 120' Sandy Limestone
120' / 140' Sandstone
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12. REMARKS:
•
it
JUN ¶ 9
ttl'iormation
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCT N STANDARDS, AND THAT A COPY OF THIS
ICIiRD HAS B EN PROVIDED T rHE WELL OWNER.
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SIGNATURE OF CERTIFIED WELL C�RAC-TOR
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING
TTHE WELL
AuG F2rre aa2
Rev. 2/09
05/21/12
DATE