415154_Well Construction - GW1_20130812

WELL CONST i':JCTYON RECO D
This form can be used for single or multiple wells
I. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: W 13-020H
List all applicable mall construction permits 0.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Obligation
❑ Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Recovery
°Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under I/21 Remarks)
4. Date Well(s) Completed: 7/1/13
5a. Well Location:
H & H Construction
Facility/Owner Name
Lot 36 Pinnacle Ridge
Well ID#
Facility ID# (if applicable)
Physical Address, City, and Zip
Pender
4204468844
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, 25, 14 N 77, 39, 25
W
6. Is (are) the w•ell(s): ©Permanent 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 name of die
repair under #2I remarks section or on the back of this form.
S. 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: 1 00 (ft.)
For multiple ,cells list all depths if different (example- 3 L''00' and 2@I00D
10. Static water level below top of casing: 13 (IL)
If water level is above casing, use "+"
0-22 8", 22-100 5 7/8"
11. Borehole diameter: (in.)
12. Well construction m half -Rotary
(i.e. auger, rotary. cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 200+ Method of test: Air lift
13b. Disinfection type: HTH Amount: 3Q(CD-10%o
For Internal Use ONLY:
415154
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
f,
ft.
ft
15. OUTER CASING (for multi -cased wells) OR LINER Of applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 It
80 ft
4 in.
Sch40 _
PVC
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
to
ft
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
D.
ft
in
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
22
Bentonite
Poured
ft
ft.
ft
ft
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft
ft
ft.
20. DRILLING
LOG (atta
h additional sheets tfnece sary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type. grain size, etc.)
0 ft
8 ft
Brown Sandy Clay
8 ft
18 ft
Brown Clay
18 ft
40 ft•
Gray Clay
40 ft
69 it
Gray Sand and Clay mix
69 ft
100 ft
Limestone Rock
ft
ft.
ft
AUG 0 6 2013
21. REMARKS
LION
ubaWATERtQUALITYSEC
il1)FnRi1h9 "IriR or
22. Certification:
ktle
gnhturee ofCertif d4d'ell omit
7/1/2013
Date
By signing this Jhnn, I hereby cart?* that the well(s) was (were) connected in accordance
with ISA NCAC 02C .0100 or I5A 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 beck of this page to provide additional well site details or well
construction details. You may also attaoh additional pages if necessary.
SUBMITTAL INSTUCT)ONS
24a. For All Wells: Submit this form within 30 days of completion of well
oonstruotion to the following:
Division of \rater Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In additi t sea 6htt r o �redd s in 24a
above, also submit a copy of this f�a tthf '0' agslIoeBi� plotip of well
construction to the following:
A YG elil C2Ce13
Division of Rater Quality, Un�r¢round n)e 1 Pr�gMam,
1636 Mail Sent Ce '•-fN3pt., Raleigh, NC 27699-1636 t�n�
24c. For Water Supply & Injection \\:'e'lisr-In-addition-tosending h{ lorm to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the count' 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