413236_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 13-009 H
List all applicable well constriction permits (i.e. Combs, State, Variance, etc.
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geotllennal (Heating/Cooling Supply)
❑ lndu strial/Commercial
°Irrigation
❑MunicipaVPublic
BResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
°Monitoring ❑Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑ Aquifer Test
°Experime tal Technology
oOeotheital (Closed Loop)
❑ Geothemral (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
It.
n
R
15. OUTER CASING (for multi -cased wells) OR LINER (if ap i livable)
FROM
TO
DIAMETER
TRICKINESS
MATERIAL
+1.5 R
90
4
in.
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
n
in.
R
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
in.
f.
ff.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
24
fl.
Grout
Poured
a
a
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
R
MATERIAL
EMPLACEMENT METHOD
rt.
R
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0
f.
TO
72
DESCRIPTION (color hardness, soiVrock type, grain sire, etc.)
Sandy clay
4. Date Well(s) Completed: 04/1 O/13 Wrell ID#
5a. Well Location:
H&H Homes
Facility/Owner Name Facility ION (if applicable)
456 Pinnacle Parkway (Lot #53 Pinnacle Ridge)
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)
34 25.256 N 77 39.348
6. Is (are) the well(s): ©Permanent or ❑Temporary
72 it
120 R
Limestone
f.
IL
R
rt.
rh
21. REMARKS
R
APR `l, (3 2013
eta re, er grn—F55A
+A lht Rl 1IIALN.11.5ER' tr'y
iNFORMATIOit PROCE,v IhL styli
W e.
22. Certification:
, Y) 0_
5'ngnature of Certified Well Co
7. Is this a repair to an existing well: Oyes or DNo
Irtbis is a repair, fill out brown well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the sane constriction, you can
subnzit one form.
9. Total well depth below land surface: 120
For nidtiple wells list all depths ifdifferent(example- 3 200' and 2 r@i 100')
10. Static water level below top of casing: 12
/(water level is above casing use "+•"
11. Borehole diameter: 4 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push etc.)
(R.)
(It.)
FOR WATER SUPPLY WELLS ONLY•
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3ciQ(7, 10%
04/10/13
Date
By signing this form, 1 hereby c' hat the 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 foil 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 four 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 Supple & Injection 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