412368_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 Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit#: W13-004H
Lin all applicable well construction permits (i.e. Count)) State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgticultural
OGeothermal (Heating/Cooling Supply)
Olndustrial/Commercial
Mitigation
OMunicipal/Public
lrJResidential Water Supply (single)
OResidential Water Supply (shared)
Non -Water Supply Well:
oMonitoring ORecovery
Injection Well:
OAquifer Recharge
OAquifer Storage and Recovery
OAquifer Test
Experimental Technology
OGeothermal (Closed Loop)
OGeothertnal (Heating/Cooling Return)
OGroundwater Remediation
OSalinity Barrier
OStormwater Drainage
❑ Subsidence Control
O Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 02/11/13 Well ID#
5a. Well Location:
H&H Homes
Facility/Owner Name
Lot #51 Pinnacle Ridge
Facility ID# (if applicable)
Physical Address, city, and Zip
Pender
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
For Internal Use ONLY:
412368
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft
15. OUTER CASING (for multi -cased wells) ORLINER (if applicable)
FROM THICKNESSMATERIAL
+1.5 R PVC
TO
90 ft.
DIAMETER
4
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
TmcEr4ESS
MATERIAL
ft.
in.
ft.
ID.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
24 ft.
Grout
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (colar,hardness, soiurocktvpe. grain size, etc)
0
ft.
75 R.
75
80 R•
Sand to clayey sand
Sandy limestone
go ft.
115 R•
Limestone
ft.
ft
fL
ft.
ft.
ft.
21. REMARKS
R.
MAR 1 4• %'013
%ATP QtlAlITV SECTION
BNFORMATION PROCESSING UNIT
22. Certification:
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: OYes or RINo
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 of this form.
S. Number of wells constructed: 1
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: 115 (ft.)
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100')
10. Static water level below top of casing:
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.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 100+ Method of test: Airlift
13b. Disinfection type: HTH Amount: 3qA10%
Signature of Certified Well C
02/11/13
Date
By signing this form, 1 hereby cer fy that the well(s) was (were) constructed in accordance
with ISA 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 Riled -ion 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 Cen(ertRaleig)irN�7 39`1t1� I1'
VXYr�'t kl s 1i``,,�..
24e. For Water Supply & Injection ells:
the address(es) above, also submit *cop
completion of well construction to thg ` un
where constructed.
nit)
addition to sending the orin to
of �is o I�1� 30 daps of
A§Flth d ar rit)of the Zonnty
el �'
Form GW-I
North Carolina Department of Environment and Natural Resources- Division of Water Qualitd4Y:--- ----------Revised Iran. 2013