412458_Well Construction - GW1_20130408

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531
NC Well Contractor Certification Number
Applied Resource Management, PC
Company Name
2. Well Construction Permit if:NA
List all applicable well construction permits Be. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commeroial
❑Irrigation
OMunicipal/Publio
o Residential Water Supply (single)
o 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 Rehm)
❑Groundwater Remediation
Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/11/13 Well ID# MW-2
5a. Well Location:
Hampstead Town Center
Facility/Owner Name Facility ID# (if applicable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and Zip
Pender 3293-86-8315-0000
County Parcel IdentificationNo. (PIN)
5b. Latitude and Longitude in degrees/tninutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
24 deg. 23' 29.21" N 77 deg. 40' 39.74"
6. Is (are) the well(s): °Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or ONo
If this is a repair, fill out blown well construction information and explain the nature of the
repair under #21 remain section or on the back of this form.
8. Number of wells constructed: 4
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: 18 (ft)
For multiple wells list all depths ifdif(erent (example- 3©200' and 2Q100)
10. Static water level below top of casino: 8.41
Ifuater level is above casing, itse "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(ft)
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
7 ft
18 ft
Surficial
ft
it.
15. OUTER CASING (for multi -eased wells) OR LINER (flap licable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
+2 ft
3 ft
2 in,
SCH-40 PVC
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO I.
DIAMETER
THICKNESS
MATERIAL
ft
ft
In.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
3 ft
18 ft
2 i"'
0.010
SCH-40
PVC
ft
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
1.5 ft
Bentonite
Poured
ft.
ft
ft
ft
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1.5 ft
18 it
Coarse Sand
Poured
ft
ft.
20. D1ULLINGLOG
(attach
additional sheets If necessary)
FROM
- TO
DESCRIPTION (color, hardness, soil/rock type, grain sisa era)
ft
ft
See attahced.
ft.
ft.
ft
ft.
ft
ft.
ft
MAR 2 5 cii3
ft
ft
rt
It
ihF WAi'ER°WILIYYSE=CTiI N
�"If6RAiiQ
21. REMARKS �RSIt;E"SSlldi: UNIT
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
Siedatore of Certified V(ell Contractor
Date
By signing this form {I hereby certifr that the wel(?) was (were) constructed in accordance
with 15A;CAC 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 1{ r E -a0 `- s.`+ letion of well
construction to the following: fp]� `f
Division of Water § jlity!ihtit•neln9rymssin i)lit,
1617 Mail Sers nter, RaleigR, Nt 4899-
Inc.
24b. For Infection Wells: ^ddd' ' ending the form t address in 24a
above, also submit a copy of this form within completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. 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.