412367_Well Construction - GW1_20130318

WELL CONSTRUCTIION 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 #: W13-003H
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
THICKNESS MATERIAL
+ PVC
FROM
ft
TO
90
DIAMETER
4
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
in.
ft.
ft.
17. SCREEN
Water Supply Well:
OAgricultural
OGeothermal (Heating/Cooling Supply)
Olndustrial/Commercial
Olrrigation
OMunicipal/Public
®Residential Water Supply (single)
DResidential 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 Retum)
OGroundwater Remediation
❑Salinity Battier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #2I Remarks)
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
fa
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
22 ft.
Bentonite
Pumped
ft.
It.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
£t.
ft.
R.
20. DRILLING LOG (attach addidonal sheets if necessary)
FROM
0
ft.
TO
10
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
Fine silty sands
4. Date Well(s) Completed: 02/13/13 Well ID#
5a. Well Location:
H&H Homes
Facility/Owner Name
Lot #24 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: 22. Certification:
(if well field, one lat/long is sufficient)
10 ft
25 ft.
Gray clay
25 It
73
Gray fine silty sands
73 fL
125 ft
Soft to hard limestone rock
ft.
ft.
ft
ft.
ft.
21. REMARKS
MAR t G: 7111
W
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: OYes or ENo
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.
8. 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: 125 (ft)
For rnuldple wells list all depths ifd4erent (example- 3Q200' and 2 t@l00')
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
(ft.)
(i.e. auger, rotary, cable, detect push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gum) 100+ Method of test: Airlift
13b. Disinfection type: Hl"H Amount: 3Cla1 O%
Signature of Certified Well ontraetor
WATER QUALITY SECTION
INFORMATION PROCESSING UNIT
02/13/13
Date
By signing this form, I hereby certify !ha 1(s) was (were) constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC t . 00 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 fowl 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 fowl within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service e n 1 4i 1
24c. For Water Supply & IniectioH Wells: In addition to sending teWonn to
the address(es) above, also submit one M �) u t)ti%�ffo %'vdjthsn 01 days of
completion of well construction tq� the c {' �' ` ea ti de h7dbnt b' kite county
where constructed.: f'
Form GW-1
North Carolina Department of Environment al
d Natural Resources —Division of Water Qtalii'ty'-
Revised fan. 2013