413323_Well Construction - GW1_20130511

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #: W 13-013 H
List all applicable well consmtcfioa permits Be. County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
A13323
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
n
n
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
+1.5 n 85 tc 4 In. PVC
16,.INNER CASING OR TUBING (geothermal closed=loop):
FROM
TO
DIAMETER
THICh1NESS
MATERIAL
n
ft.
in.
n
in.
17. SCREEN.
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
DIndustrial/Commnercial
o Irrigation
o Municipal/Public
®Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑ Sal nity Barrier
❑Stonnwater Drainage
❑Subsidence Control
DTracer
Dotter (explain under #21 Remarks)
4. Date Wel(s) Completed: 04/08/13 ;cell ID#
5a. Well Location:
Riptide Builders
Facility/Owner Name
Facility ID# (if applicable)
209 S. Kingfisher Ln. ( lot # 12 Tidewater Landing)
Physical Address, City, and Zip
Pender
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latdong is sufficient)
6. Is (are) the well(s): ©Perumnent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or DNo
If&is is a repair, fill out blown well cnnsbmcdnrr information and explain the nature oldie
repair wider #21 remarks 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 construction, you can
submit one form.
9. Total well depth below land surface: 105
For multiple wells list all depths ifdii ferert (emmple- 3©200' and 2 t@100)
(ft.)
10. Static water level below top of casing: 20 (1t.)
)(water level is above casing, use "+'•
11. Borehole diameter: 4 (in)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gprn) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3gnn, 10%
FROM
TO
DIAMETER
SLOT SIZE
THICENESS
MATERIAL
ft.
in.
ft.
in.
18. GROUT,.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
25 n
Grout
Pumped
ft.
n
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
n
n
20. DRILLING LOG (attach additional sbeets ifaccessary)
FROM
0
n
78 n
TO
78
105 n
DESCRIPTION (color, hardness, soirrecktrpe, grain size, etc.)
Sandy clays
Limestone
n
n
MAY m 3 21J1.3
It.
n
21: REMARKS
WATER QUALITY SECTION
INFORMATION PROCESSING UNIT
22. Certification:
Signature of Certified Well Con
04/08/13
Date
By signing this form, 1 hereby cern), 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 if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this f �i"S of well
construction to the following: a�
Division of Water Qualit*Inforkilfifin•frp
1617 Mail Service Cen{et, RaleI h, Ne 27
24b. For Infection Wells: In additioiin to sending the fonn to the a.. ress in 24a
above, also submit a copy of this form ttithir 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 Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn 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