415156_Well Construction - GW1_20130812

WELL CONSTRUCTION RECO
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald H. Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: W-1 3-040H
List all applicable well construction permits (i.e. Coma,. State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well•
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
°Inigation
❑Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
o Monitoring
o Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
o Esperimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 7/8/13
5a. Well Location:
H & H Construction
❑Groundwater Remediation
❑Salinity Barrier
❑ Stonnwater Drainage
❑Subsidence Control
°Tracer
DOther (explain under 421 Remarks)
Well ID# N/A
N/A
Facility/Owner Name Facility ID# (ffapplicable)
Lot 45 Pinnacle Ridge, Hampstead, NC 28443
Physical Address, City, and Zip
Pender 4204-47-6579-000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laUlong is sufficient)
34, 25, 22 N 7739, 28
W
6. Is (are) the well(s): I:Pernaanent or ❑Temporary
7. Is this a repair to an existing well: °Yes or °No
If this is a repair, fill out known well construction information and explain the nantre of the
repair under 421 remark section or on the back of this form.
8. Nuinber of wells constructed: 1
For multiple injection or non-unter supply wells ONLY with the sane construction, you can
submit one form.
9. Total well depth below land surface: 265 CM)
For multiple wells list all depths if different (example- 3®200' and 2Q100)
10. Static water level below top of casing: 12 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 5 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Air lift
13b. Disinfection type: HTH Amount: 3gA10%
For Internal Use ONLY:
415156
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap dicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft
235 ft
4 in•
Sch40
PVC
16. INNER CASING OR TUBING (geothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
ft
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
H,
In
ft.
H,
in
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 it
45 ft
Grout
Poured
225 ft
230 ft
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL
PACK(if
applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
230 It
265 ft
Course sand
Poured
f4
ft.
20. DRILLING
LOG (atta
h additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
0 rt
12 ft.
Sand
12 ft
67 ft.
Sandy clay/clay
67 ft
135 ft
Limestone
135 ft
150 f •
Clay/medium
150 ft
235 ft
Rock/sand mix
235 ft
265 ft
Sandstone
ft.
ft.
21.REMARKS
AUG0 �(+
G F:: 2013
WATFR CAI IAt ITV SECTION
22. Certification:
Signs etur ofCen edI ell Contractor
MATION PROCESSING UNIT
N, r
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15.4 NCAC 02C .0100 or I5A NCAC 02C .0200 Well Canso -action Standards and that a
copy of this record has been provided to the well comer.
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 Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In adta to n r
above, also submit a copy of thj j rm wr m .(T'
construction to the following:
e address in 24a
of toruldtion of well
AUG 12 r//ttl1�����Qr
Division of Water Quality, 4 erground Injectidilrafuro{P(ogram,
1636 Mail Service tf ter, Raleigh, NC 27699-16/
24c. For Water Supplv& Iniectid�h'1�//Welise 7n sddi iflnisending-the form to
the address(es) above, also submit one copy of this fonm 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