410879_Well Construction - GW1_20130204

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2531A
1. WELL CONTRACTOR:
H. Michael Saoe
Well Contractor (Individual) Name
Apolied Resource Management. P.0
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# H-0405
OTHER ASSOCIATED PERMIT#Of applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply MS
DATE DRILLED 01/04/13
TIME COMPLETED 2:30
AM ❑ PM Le
4. WELL LOCATION:
CITY: Hampstead couNTY Pender
99. Scrub Oaks Dr. Lot #14 Pinnacle Ridge
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley RfFlat ❑Ridge ❑Other
LATITUDE 34 ° 25 18.0200 "DMS OR
LONGITUDE 77 ° 39 2.1300 "DMS OR
Latitude/longitude source: IGPS ['Topographic map
(location of well must be shown on a USGS top() map andattached to
this form if not using GPS)
6. WELL OWNER
H&H Homes
Owner Name
825 Gum Branch Road # 119
DD
DD
Street Address
Jacksonville NC 27540
City or Town State Zip Code
910 ) 263-5186
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 125'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Pr
c. WATER LEVEL Below Top of Casing: 14' FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surfacemay require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gam): 100+ METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount Scud 10%
Top
Top
Top
f°°(O.t r y V
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 100' Ft. 4" SCH40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 25' Ft. Bentonite Pumped
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 FL in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Bottom_ Ft.
Bottom Ft.
Bottom Ft.
11. DRILLING LOG
Top Bottom
0' /25'
25' / 75'
75' / 125'
/
12. REMARKS:
Formation Description
Gray clay
White to pray fine silty sands
Medium to hard limestone rock
..FFH fl4 2U13
I DO HEREBY CERTIFY THAT, THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF T IS RECORD HAS BEEN
PROW DED TO THE WELL OW
12/12/12
NATURE OF CERTIFIED DATE
H. Michael Sage
..-PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
RECEIVED
JAN 2 8 209?
Form GW-la
Rev. 2/09
Information Pm:resp�W). nit