406309_Well Construction - GW1_20120820

OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
RESIDENTIAL., ONWELL 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
City or Town
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC 28443
State Zip Code
: 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 Amount 3g (10 %
: g. WATER ZONES (depth):
Top Bottom Top
: Top Bottom Top
Top Bottom Top
Bottom
Bottom
Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top +1.5 Bottom 120' Ft. 4" sch40
: Top 0' Bottom 80' Ft. 6" sch40
Top Bottom Ft.
:• 8. GROUT: Depth Material
Top 0' Bottom 80' Ft. Grout
: Top 0' Bottom 26' Ft. Grout Tremmie
Top 112' Bottom 116' Ft. Bentonite Tremmie
Material
PVC
PVC
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigatiord 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: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0Slope ❑Valley 0Flat ❑Ridge ❑Other
LATITUDE 34 ° 9 14.6400 " DMS OR DD
LONGITUDE 77 ° 51 ' 34.1500 " DMS OR DD
Latitude/longitude source: IGPS ❑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
Georae Escaravaae
Contact Name
92 Pelican Point Rd
Mailing Address
Wilminaton Ne 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 qI
c. WATER LEVEL Below Top of Casing: 12'
(Use "+" if Above Top of Casing)
FT.
Method
Pressure
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 Size Material
Top 116' Bottom 140' Ft. #2 Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 40' Sand to fine to coarse
•
40' / 60' Clay
•
60' / 110' Limestone
.
• 110' / 120' Sandy Limestone
• 120' / 140' Sandstone
.
•'Y
•
/
JUN 2, 9 2°12'
: 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
CARD HAS BEAN PROVIpED TjOrHE WELL OWNER.
SIGNATURE OF CERTIFIED WELL C
•
• Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTI;NG:TH.E,,WELL
•
ry 05/21/12
TRACTOR DATE
Submit within 30 days of completion to: Division of later Quality - Information Processin
9s
1617 Mail Service Center, Raleigh, NC 27699-161, :Phone : [phone]
AUG 2FrVlb
(4,,
12. REMARKS: