413161_Well Construction - GW1_20130429

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1 3181
1. Well Contractor Information:
H. Michael Sage
Welt Contractor Name
2531A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
DGeothermal (Heating/Cooling Supply)
DIndustrial/Cone nercial
DIrriiation
DMunicipal/Public
❑ResidentialWater Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
C1Monitoring DRecovery
Injection Well:
DAquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test D Stortnwater Drainage
❑Experimental Technology DSubsidence Control
DGeothermal (Closed Loop) ❑Tracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Wells Completed: 0 3/2 0/ 13 Well ID# Dove Field
5a. Well Location:
Belvedere Property Mgmt
Facility/Owner Name
Facility ID# (if applicable)
8682 Telegraph Rd. SE, Winnabow, NC 28479
Physical Address, City, and Zip
Brunswick
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
N W
6. Is (are) the well(s): ❑Permanent or DTemporary
7. Is this a repair to an existing welt: uYes or vivo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 143
For multiple wells list all depths if different (example- 3@200' and 2@I00')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
14. WATER ZONES ..
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15`OUTER
CASING (for multi
-cased wells) OR LINER. (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
60 ft.
8 in.
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
. THICKNESS
MATERIAL
+1.5 ft.
103 ft.
4 in.
PVC
ft.
ft.
in.
17:SCREEN
.
.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
103 t
143 ft
4 in.
.20
PVC
ft.
ft.
in.
ISGROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
25 ft.
Bentonite
Poured
90 ft
95 ft.
Bentonite
Poured
ft.
ft.
19 SAND/GRAVEL PACK (if applicable)' ;
FROM
TO
MATERIAL
EMPLACEMENT METHOD
95 ft
143 ft
Sand
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
See Attached
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
APR242013
ft.
ft.
21 REMARKS` ...,.
QUR SECTION
NFQRWATERMATJ N PROCITYESSING
UNIT
11. Borehole diameter: 8
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(in.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 150+ Method of test: Airlift
13b. Disinfection type:
Amount:
22. Certification:
03/20/1 3
ignature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit thin orm 30 days of com
construction to the following:
Division of Water Qu y iT, Information Processing U
1617 Mail Service e tp, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
n of well
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Simply & Infection Wells: In addition to sending the form to •
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health departrnent of the county
where constructed.
Form GW 1
North Carolina Department of Environment and Natural Resources — Division of Water Qualify Revised Jana 2013

Orton Plantation
Dove Field
Drilled By: H. Michael Sage
Date: 3/20/13
0 -25
Sandy clay
25-35
Marl - shell, sand, and rock
35 - 55
Limestone rock
55 - 93
Gray clay / silty clay
93-143
Sandy limestone / sandstone mix