414218_Well Construction - GW1_20130617

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For internal Use ONLY:
14. WATER ZONES
1. Well Contractor Information:
Harry Michael Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, PC
Company Name
2. Well Construction Permit #: irrigation
List all applicable well construction permits (i.e. Couny', State, Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
o Agricultural
❑Geothermal (Heating/Cooling Supply)
o Industrial/Commercial
O Inigation
o Municipal/Public
o Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring DRecovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
o Experimental Technology
DGeothennai (Closed Loop)
°Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
o Other (explain under#21 Remarks)
FROM
TO
DESCRIPTION
ft
ft
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if k bl )
FROM
TO
DIAMETER
SCH40
app PVC
THICKNESSea e
� MATERIAL
0
ft
60 ft.
4
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
fe.
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
20 '
Bentonite Chi
Poured
ft
ft
ft
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft
ft
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0 ft.
TO
10 ft
DESCRIPTION (color, hardness, soimrnck type, grain size, etc.)
Tan/Brown fine sand
4. Date Well(s) Completed: 5/15/13 `yell my Irrigation Well
5a. Well Location:
Muting Rui
Facility/Owner Name
809 Grandview Drive
Facility ID# (if applicable)
Physical Address, City, and Zip
Hampstead, NC 28443
R0361901532000
County n .I�fi�i'r Parcel Identification No. (PIN)
5b. Latitude and Longitude in egrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
34 22 31.8 N 77 41 13.85
6. Is (are) the well(s): LaPermanent or °Temporary
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair, fill out known well construction h1fornration 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 wells OA'LPwith the sante construction, you can
submit one fora.
9. Total well depth below land surface: 87
For multiple wells list all depths ifdiferent (example- 30200' and 2@10(r)
(ft)
10. Static water level below top of casing: 11 (ft)
If water level is above casing, use "+"
11. Borehole diameter: 5-7/8 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
10 it
20 ft
Reddish brown clay
20 ft
40 ft
Gray clay with shell
40 ft.
87 ft.
Soft to very hard limestone rock
ft
ft.
ft
ft
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) >100 Method of test: Air-lift
13h. Disinfection type: Granular Chlorine amount: 1/2 Ib.
ft
ft
21. REMARKS
N 1. 7 ?nil
WAFER QUALITY SECTION
INFORMATION PROCCS°INIC UNIT
22. Certification:
gnature of Cerjffied Well Contractor
ate
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15,4 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 well site details or well
construction details. You may also attach additional pages
SUBMITTAL INSTUCTIONS A .
24a. For All Wf ells: Submit this w MIT
.1 r1 p14 n"t) of well
construction to the following: J1.11"d q 5
Division of Water Qualit,•, fnformation Processing Unit
1617 Mail Service Cent;WR,aleighrNC-2..7699-1E17-
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copyof this -form -within 30-days-of-completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Senice Center, Raleigh, NC 27699-1636
24c. For Water Suoplr & iniecfion 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.
Fonn OW-1
North Carolina Department ofEmironment and Natural Resources -Division ofV,ater Quality Revised ]an. 2013