413295_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 13-014 H
List all applicable well coma-net/on permits (i.e. Cowry, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
413205
14. WATER ZONES
FROM
TO
DESCRIPTION
IL
R
R
15. OUTER CASING (for multi -cased wells) OR LINER (if ap diastole)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5
85
R
4
in.
PVC
16. INNER CASING OR TUBING (geothermal closed400p)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
R
R.
in.
R
in.
17. SCREEN
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑MunicipallPublic
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring ❑Recovery
Infection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
°Groundwater Remediation
❑ Salinity Barrier
❑Stoemwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: 04/09/13 Well ID#
5a. Well Location:
Riptide Builders
Facility/Owner Name Facility ID# (if applicable)
193 S. Kingfisher Ln. ( lot # 13 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 Iat/long is sufficient)
N W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or IENo -
If this is a repair, fill out blown well consartction information and explain the nature of the
repair lender 021 remarks section or on the back gfthisform. •
8. Number of wells constructed:
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 if different (example- 3©200' and 2Q100')
(It)
10. Static water level below top of casing: 20 (R,)
Ifwater 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 (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3g1wli1 0%
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
R
in.
R
R.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
R
25
R
Grout
Pumped
R
R
R
R
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
R
R
R
R
20. DRILLING LOG (alto h additional sheets if nec ssa
FROM
0
78
TO
78 a-
105 R
)
DESCRIPTION (color, hardness, sell/rock tvpe, grain size, etc)
Sandy clays
Limestone
R
R
R.
R
R
R
APR 3 0 2013
R
R
WATFR 01 IAI ITY SFCTI ON
21. REMARKS JjFORMATION PROGFRSINf IINIT
r
22. Certification:
D,Ja
Signature of Certified Well Contracto
MAY 0 6 20J3
04/09/1 pi
Date
By signing this form, I ha'ebv cerfif' thnti(e well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A 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 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 Injection Wells: In addition to sending the form 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 foam 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