415167_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells
POT Internal Use ONLY:
I. Well Contractor Information:
Christopher Blackmon
Well Contractor Name
4145-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: W 13-035 H
List all applicable well construction permas (.e. County, State, Variance, etc.)
3. Well Use (check well use):
415167
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if apStable)
FROM
0
ft.
TO
75 ft.
DIAMETER
4
in.
p
MATERIAL
Sch40 PVC
THICKNESS
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
in.
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooing Supply)
❑ Industriai/Commercial
❑Irrigation
o Municipal/Pubhc
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring °Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
o Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remediation
❑Salinity Barrier
°Stormwater Drainage
❑Subsidence Control
o Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 7/8/13
5a. Well Location:
H & H Construction
Facility/Owner Name
Lot 46 Pinnacle Ridge
Well ID#
Facility ID# (if applicable)
Physical Address, City, and Zip
Pender
4204-47-5574-000
County Parcel IdentificationNo. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
(if well field, one latilong is sufficient)
34, 25, 21.35 N 77, 39, 30.98
6. Is (are) the well(s): EPermanent or °Temporary
W
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on Me back of this
8. Number of wells constructed: 1
For eudople injection or non -outer supply wells ONLY with the same canon nion you can
submit one foram.
9. Total well depth below land surface: 95 (ft.)
For multiple wells list all depths if different (avample- gC 00' and -'Qa 100)
10. Static water level below top of casino: 12 (ft.)
If water level is above casing, use "+"
1I. Borehole diameter: ')-228", 22-98-6"(in.) -- -.
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SLTPPLY WELLS ONLY:
13a. Yield (gpm) 100+ Method of test: Air lift
13 b. Disinfectionnpe: HTH Amount: 3q 10%
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
In
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft
40 k
Bentonite
Poured
ft
n.
ft.
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft
ft.
20. DRILLING LOG (attach additional sheets if nece saint)
FROM
0
ft.
TO
15
DESCRIPTION (color, hardness, soil/reek type, grain size, etc.)
Sand
15 ft
50.
Sand and clay mix
50 m
98 ft.
Hard limestone
ft
ft.
ft
ft
ft
AL%lire 6113
21. REMARKS
WATER SEC TO
22. Certification:
Signature ofCertifi d Wei, Contractor
Date
By signing this form, 1 hereby certih' that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C.0/00 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 page to provide additional we to ail q well
m u, construction details. You may also attach' aa�taor m14. pe
kl AVq T
onq mhin a ay o completion pfilwell
y;If°
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this
construction to the following:
Division of Water Quality, IMOOititation-Premegsiere Uffitr '
1617 Mail Service Center Raleigh, NC 27699-1617
24b. For Injection 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 Seviee Center, Raleigh, NC 27699-1636
24e. For Water Simply & Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this fonn 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