413296_Well Construction - GW1_20130506

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 13-01 5 H
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
'Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Olrrigation
❑MunicipaVPublic
®Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
Injection Well:
OAquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
OGeothennal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date N'ell(s) Completed:
5a. Well Location:
Riptide Builders
ORecovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
04/08/13 well ID#
Facility/Owner Name Facility IDE (if applicable)
177 S. Kingfisher Ln. ( lot # 14 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 lat/long is sufficient)
N W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑ Yes or ENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or an the back of this form.
8. Nmnber of wells constructed: 1
For nudtiple 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 if different (example- 3 r@200' and 2 100')
(It)
10. Static water level below top of casing: 20 (R,)
!Netter level is above casing, use "+"
11. Borehole diameter: 4
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (ggpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3q(a7 10%
For Internal Use ONLY: W ; 1 !1
413296
14. WATER ZONES ,.
FROM
TO
DESCRIPTION
R.
R.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifap licable).-.
FROM
TO
DIAMETER
THICKNESS MATERIAL
+1.5 B'
85 L
4 In.
PVC
16. INNER
CASING Olt TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
a
n
in.
a
fL
in.
17. SCREEN:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
a
0.
in.
tt
ft
im
18. GROUT r -
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 tt
25 n
Grout
Pumped
B.
a
ft
a
19.SAND/GRAVEL
PACK
Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
tt
ft.
ft.
n
' 20. DRILLING
LOG (atta
Radditional sheets if necessary) -'
FROM
TO
DESCRIPTION (color, hardness, roll/rocktype grain size, etc)
0 ft-
78 n
Sandy clays
78 R-
105 ft
Limestone
ft
ft.
per-
a.
a
y A
rt.
a
lY
e 0 0 2017 i
ft.
n
APR 3O
b/_----�^_-�.�_.
13
n.
a
21. REMARKS WAI:ER DUALITY Sti l
ION
INFORMAn0N PROCESSING UNI
22. Certification:
Signature of Certified Well Contractor
04/08/13
Date
By signing this form, I hereby cer$jft that the vas (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Consbvetion 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 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: In addition to sending the fonn to the address in 24a
above, also submit a copy of this 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 Supply & Injection 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