412518_Well Construction - GW1_20130408

WELL ELL CONSTRUCT, N REC
(,gig
1
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. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
E l Irrigation
Non -Water Supply Well:
❑Monitoring
DMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
DRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Rem ediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (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 W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or DNo
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: 1
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: 260' (ft)
For multiple wells list all depths if different (example- 3200' cnr.and 2@100')
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
MATERL4L
ft.
ft.
in.
16. INNER
CASING OR TUBING
geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft.
220 ft.
4 in.
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
220 ft.
260 ft.
4 in'
.010
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
20 ft•
Grout
Pumped
ft.
ft.
ft.
ft.
ffb
CI w � 1
k 0s
i p . t fs via s..
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
WATER QUALITY SECTION
0MA TI Olin PROCESSING UI
ft.
ft.
ti
20. DRILLING LOG -(attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soilrock 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
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: HTH Amount: 3 g 10%
22. Certification:
02/25/13
Signature of Certified Well • ctor Date
By signing this form, I 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 pageto • _ ovide ad�� i • ,w ails or well
construction details. You may als
SUBMITTAL INSTUCTIONS
i rm . ` i a � �i�
24a. For All Wells: Submit thy ompet on of well
construction to the following:
s-i,�,
Division of Water Quai�,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
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.
IT
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013