403633_Well Construction - GW1_20120206

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quali
WELL CONTRACTOR CERTIFICATION # 347Q A
1. WELL CONTRACTOR:
William Matthew Wiggins
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
State
28443
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) Loop 2
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other Ci(list use) Geothermal Loop
DATE DRILLED 0 1 /26/2012
4. WELL LOCATION:
6425 Shinnwood Dr.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington couNTYNew Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley WifFlat ❑Ridge DOther
LATITUDE 34 ° 11 ' 48.1300
LONGITUDE 77
49 ' 51.4600
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: UPS ❑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
Al Fulford Heatina & Air
Contact Name
3461 Holden Beach Rd SW
Mailing Address
SuDDIV NC 28462
City or Town State Zip Code
( 910 ) 842-6589
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: N/A
(Use "+" if Above Top of Casing)
YES ❑ NO qi
FT.
40
: d. TOP OF CASING IS 0 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): N/A METHOD OF TEST NIA
: f. DISINFECTION: Type N/A Amount N/A
: g. WATER ZONES (depth):
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Material Method
Top 0 Bottom 250 Ft. Thermex Tremmie
i Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top Bottom Ft. in. in.
: Top .Bottom . Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0' / 25'
25' / 50'
50' / 80'
80' / 140'
140' / 245'
245' / 260'
/
Size
Material
Formation Description
Silty sands
Clay / shell
Limestone
Clay mudrock
Sandstone
Silty clay
12. REMARKS:
1" geothermal HDPE Loop installed
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECORD HBEEN PRQVID _ HEWL O1/;' RER.
SfGNATURE OF C
RTIFIED WELL
William Matthew W{q
• PRINTED NAME OF PERSO CONSTRUCTING THE WELL
RAC —TOR
01/26/12
DATE
•
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Set -vice Cennter, Raleigh, NC 27699-161, Phone [phone]
Form GW-lb
Rev. 2/09
4