412369_Well Construction - GW1_20130318

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 Connector Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #: W 13-008H
List all applicable well construction permits (.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
OAgricultural
OGeothermal (Heating/Cooling Supply)
OIndustrial/Commercial
Olrrigation
OMunicipal/Public
BResidential Water Supply (single)
OResidential Water Supply (shared)
Non -Water Supply Well:
OMonitoring ORecovery
Injection Well:
OAquifer Recharge
OAquifer Storage and Recovery
OAquifer Test
OExperimental Technology
OGeothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
OOther (explain under #21 Remarks)
4. Date Well(s) Completed: 02/12/13 Well m#
5a. Well Locgtion:
H&H Homes
Facility/Owner Name
Lot #30 Pinnacle Ridge
Facility ID# (if applicable)
Physical Address, City, and Zip
Pender
County Parcel Identification No. (PIN)
For Internal Use ONLY:
412369
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifap licahle)
FROM
TO
DIAMETER
THICKNESS MATERIAL
+1.5 ft•
90 ft•
4 m.
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
H.
in.
£t.
ft.
in.
18. GROUT.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 it•
24 R•
Grout
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (atta
h additional sheets if necessary)
FROM
TO
DESCRIPTION(color, hardness, soil/rock type, grain size, etc)
0 ft
40 ft.
Sand clay
40 ft•
75 ft.
Clay
75 ft•
115 ft.
Limestone
f.
ft.
ft.
ft.
ft.
ft.
H.
ft.
MAR 1 4 7013
21. REMARKS
WATER QUALITY SECTION
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification:
(if well field, one lat/long is sufficient)
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: OYes or ENNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple Infection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 1 18 (ft)
For tnultiple wells list all depths ifdiferent (example- 3Q200' and 2Q100')
10. Static water level below top of casing:
If water level is above casing, use '•+"
(ft.)
11. Borehole diameter: 4 (in.)
12. Wellconstruction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
100+ Airlift
13a. Yield (gpm) Method of test:
13b. Disinfection type: HTH Amount: 3c @ 10%
Form GW-I
North Carolina Depamnent of Environment m d Natural Resources- Division of Water Quality
Signature of Certified Well Cann
02/12/13
Date
By signing this form, 1 hereby certi ti)8II(he well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy ofthis 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 Iniection 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 & Iniection Wells ha(rt(gtq{s@irrf the torpi to
the address(es) above, also submit one c p of this form within 30 day§ 4f
completion of well construction to the co!• h(t Fippg<e 1 e gunny
where constructed. Y oMPo U,
)vv
Revised an. 2013