413294_Well Construction - GW1_20130506

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
I. 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 consovcfion permits (i.e. Cow®, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultdral
OGeotheimal (Heating/Cooling Supply)
Olndustrial/Conimercial
❑Irrigation
DMunicipallPublic
EResidential Water Supply (single)
OResidential 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
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
OOther (explain under #21 Remarks)
412294
14. WATER ZONES
FROM
TO
DESCRIPTION
n
15. OUTER CASING (for multi -cased wells) OR LINER (Ifap liceble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 a
85
a
4
in.
PVC
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
a
In.
fr.
a
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0.
in.
a
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
a
25
it.
Grout
Pumped
a
0.
a
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
p.
D.
20. DRILLING LOG (attach additional sheets If nec scary)
FROM
0
a
TO
78 a
DESCRIPTION (color, hardness, mNrocktvpe, grain alu, etc)
Sandy clays
4. Date Wen(s) Completed: 04/08/13 Well 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 hip
Pender
County Parcel Identcation No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification:
(if well field, one ladlong is sufficient)
78
105 a
Limestone
0.
ft.
0.
m
0.
a
a
APR 3 0 2013
a
a
21. REMARKS
WA t CR QUALITI3ECTION
INFORMATION PROCESSING UNIT
6. Is (are) the well(s): oPennanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or allo
If this is a repair fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back bfthis form.
8. Number of wells constructed: 1
For multiple injection or nor -water supply wells ONLY with the same construction, von can
submit one form.
9. Total well depth below land surface: 105J
For multiple wells list all depths ifdiere t example- 3®200' and 2®100')
(ft.)
10. Static water level below top of casing: 20 (ft.)
If 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:
Method of test: Airlift
13a. Yield (gpm) 80
13b. Disinfection type: HTH Amount: 3Q(i2? 10%
Signature of Certified Well Con
By signing this form, 1 hereby certify that the i4 OJ was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .b 6-Well-Eonstrrmdon-Standards-mid that
copy of this record has been provided to the well owners
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 Supplv & 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 San. 2013