414563_Well Construction - GW1_20130708

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Harry Sage
Well ContractorName
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit#: W13-048H
List all applicable well can.snuclion permits (i.e. Caunti State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
Non -Water Supply Well:
°Monitoring
❑Municipal/Public
°Residential Water Supply (single)
o Residential Water Supply (shared)
°Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
:°Aquifer Test
°Experimental Tech logy
°Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
O Stormwater Drainage
°Subsidence Control
o Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6/4/13 Well MN N/A
5a. Well Location:
Edward Peloquin
Facility/Owner Name
103 Fisher Place
N/A
Facility ID# (if applicable)
Physical Address, City, and Zip
Pender
3281-97-4832-0000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field, one lat/long is sufficient)
/r1 '7 ? �f tom.
2 ia)ft I2 �i/N lr7t/7rx1 t� firi /W
6. Is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair, jilt out known well emrsnuc/ion information and explain the nature of the
repair under /21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply well' ONLY with the snore construction, you can
.submit one form.
9. Total well depth below land surface: 215
For multiple wells list all depths ifd jerent (erample- 3@200' and 20 100')
(ft)
10. Static water level below top of casing: 15 (ft.)
If water level is above casing, use ""'
HrBorchyl.diaute e. 57/8 Out _.
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Field (gpm) 80 Method of test: Airlift
136. Disinfection type: HTH Amount: 3 lbs
S'gnanwe ofCerti ,"d Well Contracto
By signing this form, I hereby certi, that the well(s) was (were) consmtered in accordance
with 1.5A NC'AC 02C .0100 or 15A NC'AC 02C'.0200 Well Cons/nwl/on 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 well site details or well
construction details. You may also attach additional pages if necessary.
For Internal Use ONLY:
414563 \r\)(2'6
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
THICKNESS MATERIAL
PVC
0
FROM
ft.
TO
60 ft.
DIAMLILR
6
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft.
177
4
in.
PVC
ft.
ft.
in.
17. SCREEN.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
177 ft.
215 ft
4
n.
.010
PVC
ft.
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
25
Bentonite
Poured
170 ft
177 fa
Bentonite
Poured
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENTMETHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0 ft.
25 ft.
TO
25
52
ft.
DESCRIPTION (rotor, hardness. suiVrock tmq gram sise, ern
Reddish brown sandy clay
Tan medium to fine sands
52.4 .oft.
95 ft.
Hard limestone rock
95
150 "
Very soft limestone and white clay
150 rL
170 ft
-
Salt pepper sand to black PeeDee clay
170 ft.
215 ft
Medium hard to soft sandstone
ft.
ft.
21. REMARKS`
Jill_ 0 2, 2u13
WATER QUALITY SECTION
INFORMATION PROCESSING UNIT
Z.7/
a[e
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form
construction to the following:
n 30 days of completion ofi *ell
pp... JUL 0 0 2013
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
,:
2414. For 7niecfionaieps. -It+addition-te-sending-the-form-oe-theaddress-in 21'
__.
above, also submit a copy of thisis form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunulv &.Infection Wells: In addition to sending 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.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Ian. 2013