406313_Well Construction - GW1_20120820

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 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery ❑ Injection 0
Irrigation' Other 0 (list use)
DATE DRILLED 05/16/12
4. WELL LOCATION:
710 Kelly Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑ ValleyWrFlat ❑Ridge DOther
LATITUDE 34 ° 10 22.5700
LONGITUDE 77 52 32.7100
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: (BPS ❑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
Samir !sic
Contact Name
710 Kelly Rd
Mailing Address
Wilminaton
City or Town
( 910 ) 619-2419
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180'
NC 28409
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: 22'
(Use "+" if Above Top of Casing)
FT.
Submit within 30 days of completion to: Division of:'
1617 Mail Service Center, Raleigh, NC 27699-161, Phone`::
: Top 146'
Top
Top
11. DRILLING LOG
: Top Bottom
0' /
40
40' / 60'
60' / 90'
90' / 145'
145' / 180'
1• 2. REMARKS:
•
17.! ,3
: 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): +g0 METHOD OF TEST Alillft
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 150' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0' Bottom 24' Ft. Grout
: Top 142' Bottom 146'
Method
Tremmie
Ft. Bent. chips Tremmie
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 150' Bottom 180' Ft. 2" in. .020 in. PVC
Top Bottom Ft.
Top Bottom Ft.
: 10. SAND/GRAVEL PACK:
Depth Size
Bottom 180' Ft. Coarse
Bottom Ft.
Bottom Ft.
in. in.
in. in.
Material
Sand
Formation Description
Sand fine to coarse grained
Clay
Limestone
Limestone / sand mix
Sandstone
JUN 2 3 2012
intormation ProcessIng
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15 CAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• R C D HAS BEEN PRQjYIDED. "1 THE WELL OWNER.
Ont2i2.j.
SIGNATURE OF CERTIFIED WELL CO 1,'AC—TOR DATE
▪ Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING.THEWELL
05/16/12
AUG zoom W.
Rev. 2/09