406308_Well Construction - GW1_20120830

NON
a: ESIDENTIAL 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 0 Recovery 0 Injection 0
Irrigation11( Other 0 (list use)
DATE DRILLED O5/16/12
4. WELL LOCATION:
710 Kelly Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
A. I c,) •
: 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 3ga 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' Ft. Bent. chips Tremmie
Method
Tremmie
Top Bottom Ft.
9. SCREEN: Depth
Top 150' Bottom 180'
Top
CITY: Wilmington COUNTY New Han. : Top
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFIat ❑Ridge ❑Other
LATITUDE 34 c 10 ' 22.5700 "DMS OR DD
LONGITUDE 77 0 52 ' 32.7100 DMS OR DD
Latitude/longitude source: I GPS ❑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
Samir lsic
Contact Name
710 Kelly Rd.
Mailing Address
Wilmington
City or Town
( 910 ) 619-2419
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180'
State Zip Code
NC 28409
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO (/
c. WATER LEVEL Below Top of Casing: 22'
(Use "+" if Above Top of Casing)
FT.
: Top 146'
Bottom
Bottom
10. SAND/GRAVEL PACK:
Depth
Bottom 180'
Top Bottom
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
Diameter Slot Size Material
Ft. 2" in. .020 in. PVC
Ft. in. in.
Ft. in. in.
Size Material
Ft. Coarse Sand
Ft.
Formation Description
0' / 40' Sand fine to coarse grained
40' / 60' Clay
60' / 90' Limestone
90' / 145' Limestone / sand mix
145' / 180' Sandstone
/
12. REMARKS:
•
wt....I.., V7'
,s ,` r
JUN 2 9 ZO'tZ
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 PRIDEDfJ THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CO !1,'ACTOR
05/16/12
DATE
„ r
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
AUG 2 0 2O'I2
ubm�t wit in 34 days of completion to Div sIon of Water : uali
10T Mail Service Cen er,.. Raleigh, :,NC .27699 161, 'Phone [phone]:00.