412519_Well Construction - GW1_20130408

WELL C NST 1'': UCTI S N REC RD
For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. WelI Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
OGeothermal (Heating/Cooling Supply)
D Industrial/Commercial
❑irrigation
Non -Water Supply Well:
OMonitoring
❑Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
E Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
D Salinity Barrier
D Stormwater Drainage
D Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 02/25/13 Well ID#
5a. Well Location:
Harry Hart
Facility/Owner Name
293 Miracle Acres Ln.
Facility ID# (if applicable)
Physical Address, City, and Zip
Columbus
1187.00-88-4928.000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 14 13.45 N 78 23 05.17
6. Is (are) the well(s): ©Permanent or OTemporaiy
7. Is this a repair to an existing well: E Y es or iNo
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 o f this form.
8. Number of wells constructed: 3
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
a
9. Total well depth below land surface: 3 @ 255
For multiple wells list all depths if different (example- 3 a 200' and 2@100`)
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
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
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
250 ft.
1 in.
HDPE Loops
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
riVIPLACEMENT METHOD & AMOUNT -�.
ft.
ft.
ft.
ft.
ft.
ft.
MAR
- 2 6 '013
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
WATER QUAI.. Iry ECTIfN
RMA ION PROCESSING UN
ft.
ft.
N'NF
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil rock type, grain size, etc.)
0 ft.
40 ft.
Sandy clay to sandy shell hash
40 ft.
60 ft.
Cemented shell
60 ft.
80 ft.
Clay
80 ft.
83 ft.
Limestone
83 ft.
140 ft•
Clay
140 ft.
145 ft
Limestone
145 ft.
155 ft
Clay
21. REMARKS
155' to 205' - Alternating rock and clay layers (3' rock layers)
205' to 260' - Sand
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
02/25/13
Signature of Certified We 1 ContraDate
By signing this form, 1 hereby certi a well (s) was (were) constructed in accordance
with 1 SA NCAC 02C .0100 or 1 SA 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 this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Cen
24b. For Injection Wells: In additi
above, also submit a copy of this f
construction to the following:
sending the form to the adds in 24a
of c,et1leti f well
Division of Water Quality, Und ound Injection Control Pro
1636 Mail Service Cent
24c. For Water Supply & Injection 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 department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Jan. 2013