415153_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple hells
1. 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 1 3-031 H
List all applicable irel/ construction permits ('.e. County, State, Variance, et
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
o Aquifer Test
o Eaperimental Technology
o Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 07/2/13
5a. Well Location:
H & H Construction
Facility/Owner Name
Lot 44 Pinnacle Ridge
°Recovery
o Groundwater Remediation
❑Salinity Bather
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
\Well ID#
Facility ID# (if applicable)
Physical Address, City, and Zip
Pender
4204-47-7784-0000
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, 18 N 7739, 16
\W
6. Is (are) the well(s): ©Permanent or DTemporary
7. Is this a repair to an existing well: DYes or No
If this is a repair, fill out Anmrn well construction information and explain the nature of the
repair under #21 remar$s 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 constucion, you can
submit one font
9. Total well depth below land surface: 100 (f,)
For multiple wells list all depths if different (example- 3Qo 200• and 2Q100)
10. Static water level below top of casing: 14
!(enter level is above casing, use "+"
11. Borehole diame er: 5 7'8 (in.)
rfr7 •AirRota
12. Well construction me od: ry
(ft.)
(ie. anger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 200+ Method of test: Air lilt
13b. Disinfection tpe: HTH
yAmount: 3g (r7,10%
For Internal Use ONLY:
15153
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
rt
rt.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft
80 ft
4 ill'
Sch40
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)..
FROM
TO
DLAMETER
THICKNESS
MATERIAL
ft
ft
in
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft
in.
ft
p4
in.
1& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
25 ft
Bentonite
Poured
ft
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft
ft
ff.
20. DRILLING
LOG (atta
h additional sheets if nece nary)
FROM
TO
DESCRIPTION (color, hardness, solrock type, Crain size, an)
0 ft•
6 ft
White fine silty sands
6 ft•
25 ft
Gray clay
25 ft
67 ft.
Light gray, medium to fine sands and clay
67 ft
100 ft
Limestone Rock
ft
ft
ft
ft.
ft
AUG 002013
21. REMARKS
itilATFR QUALITY SECTION
itWORMA1ION PROCESSINGUINIf
22. Corti 'cation:
Gt-‘a 4
Signature of Cedilla ell Contractor
7/3/2013
Date
By signing this loon, I hereby cent(, that the well(s) uas (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Consmucdon Standards and that a
cape of this record has been provided to the well miner.
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: Ina tdf�en"d Ili dress in 24a
contraction to the follow
above, also submit a oopy of tlt s ry'yy ��'t��t+iin 2 a�3ro Room l$tion of well
mg. s itIG I Zt s
a�
Division of Water Quality', derground j nir 1 ogram,
fin
1636 Mail Servicdnter, Raleigh, NC 27699-16 ¢.j
24c. For Water Suppiv & Iniecti Wells:—in-addition-tosending 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.
Fonn GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Ian. 2013