412366_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 Pernik #: W13-002H
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgriculturai
o Geothermal (Heating/Cooling Supply)
o industrial/Commercial
°Irrigation
o Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring DRecovery
Injection Well:
o Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
o Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
o Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 02/13/13 Well ID#
5a. Well Location:
H&H Homes
Facility/Owner Name
Lot #22 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:
(if well field, one lat/long is sufficient)
N W
6. Is (are) the well(s): ©Permanent or °Temporary
7. is this a repair to an existing well: DYes or allo
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.
8. Number of wells constructed:
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 multiple wells list all depths if different (example- 3@200' and 2@/00)
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.)
For Internal Use ONLY:
A 0�1i)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft
ft.
15. OUTER CASING (for multi -eased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
+1.5 ft.
90 ft.
4 in.
PVC
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
tt,
in.
ft.
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
tt.
ft.
in.
tt.
ft,
in.
1S. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
22 ft•
Bentonite
Pumped
ft.
ft.
ff.
ft
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
R.
ft.
ff.
20. DRILLING
LOG (atta
h additional sheets if necessary)
FROM
TO
DESCRIPTION (mho, hardness, sniVrock type, grain eke, etc.)
0 ff•
10 ft
Fine silty sands
10 ft
25 ft.
Gray clay
25 ft
75 ft
Gray fine silty sands
75 u•
125 ft•
Soft to hard limestone rock
H.
ff.
ft.
ft
ft
ft.
21. REMARKS
MAR 14 2013
22. Certification:
CDia
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 100+ Method of test: Airlift
13b. Disinfection type: HTH Amount: 3q(C77,10%
Form OW-1
Signature of Certified Well Con
I I 1 atlil
INFORMATION PROCESSING UNIT
02/13/13
Date
By signing this form, I hereby cert(fy _. the well(s) was (were) constructed in accordance
with I5A 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 Infection 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, Und;
1636 Mail Service Ce
24c. For Water Supply & Infection
the address(es) above, also submit
completion of well construction to
where constructed.
BY:
North Carolina Department of Environment and Natural Resources - Division of Water Quality
nu(ection Control Program,
Fifek
•
addition to sending the,feral to
th 'l fl1j1in 30 [flays of
ee t of the county
f
Revised Sat 2013