414380_Well Construction - GW1_20130701

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2082
1. WELL CONTRACTOR:
Sanford Sweetina
Well Contractor (Individual) Name
Coastal Geothermal
Well Contractor Company Name
102 Middle St
Street Address
Jacksonville NC 28546
City or Town State Zip Code
( 910) 353-0926
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10800303
OTHER ASSOCIATED PERMIT#(if applicable) n/a
SITE WELL ID #(if applicable) n/a
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 10-01-12
TIME COMPLETED 3:00 AM ❑ mil
4. WELL LOCATION:
- - CITY: Emerald Isle .:
9704 Lord Berkley Dr.
COUNTY Carteret
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0 Slope ❑ Valley EFlat 0 Ridge ❑ Other
LATITUDE 36
LONGITUDE 75
°
" DMS OR 3X.XXXXXXXXX DD
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Bernis & Nancy Conatser
Owner Name
9704 Lord Berkley Dr.
Street Address
Emerald Isle
City or Town
(828 ) 707-0546
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 255'
•
•
•
.
•
NC 28594
State Zip Code
•
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO d
414380
g. WATER ZONES (depth):
Top 60 Bottom 140 Top Bottom
Top Bottom Top Bottom
: Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 255'. Ft. Bentonite
Top Bottom Ft.
Top Bottom Ft.
Material
Method
pump/tremie
9. SCREEN: Depth Diameter Slot Size Material
Top n/a Bottom •Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 35
35 / 60
60 /140
140 / 220
220 /255
/•
/
/
/
12. REMARKS:
Sand
Formation Description
Clay with Shells
Limestone
Silty Sand
Limestone
i
Drilled 5-255' bore holes set . `' trt4 P
mal loop in each
1 2013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
�� v�► roc L eioanr� op -or asIng:-
(Use "+" if Above Top of Casing) : STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
• PROVIDE! TO THE WELL OWNER.
d. TOP OF CASING IS n/a 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): n/a METHOD OF TEST n/a
f. DISINFECTION: Type n/a Amount n/a
SIGNA RE 0 CE
Sanford Sweeting
/0-17-�
TIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality -
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Information Processing,
Form GW-1 a
Rev. 2/09