412343_Well Construction - GW1_20130318

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 #: NA
List all applicable well construction permits (.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
oAgricultural
O Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
OMunicipal/Public
OResidential Water Supply (single)
OResidential Water Supply (shared)
Non -Water Supply Well:
(Monitoring ORecovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
O Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
OOther (explain under #21 Remarks)
4. Date Wen(s) Completed: 2/11/13 Well ID# MW-3
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/minutes/seconds or decimal degrees:
(if well field, one IaUlong is sufficient)
24 deg. 23' 23.54" N 77 deg. 40' 34.63"
6. Is (are) the well(s): ©Permanent or OTemporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out Frown well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
S. Number of wells constructed: 4
For multiple injection or non -water supply wells ONLY with the sane construction, you can
submit one form.
9. Total well depth below land surface: 16'S (ft)
For multiple wells list all depths if different (example- 3Qa 200' and 2Q100)
10. Static water level below top of casing: 6.39
If water level is above casing, use "+"
11. Borehole diameter: 8
(in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
INFORMATION PROCESSIN
22. Certification:
A_ 2 iy--L3
Signature of Celli ftfd Well Contractor Date
By signing this form, I hereby cart fy that the well(s) was (were) constructed in accordance
with 15A 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 ws$i$hin 30 days of completion of well
construction to the following: g1t14w
Division of Water Quality'Jnformation'Pr up„"srl'irg:Unit,
1617 Mail Service Cetttfr, R, fjgj(, NC 27699i-16P1 ',
I� tr ^^diZ" pp N
24b. For Iniection Wells: In additiii to sending ti or e addr ss in 24a
above, also submit a copy of thisM°ojm within 30 days mpljti4n of well
construction to the following: "�-.. (;p
Division of Water Quality, Underground InjectiontontrCpl Program,
1636 Mail Service Center, Raleigh, NC 27699-1635
24c. For Water Suooly & Iniection Wells: In addition to sending the form to
the addresses) 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.
For Internal Use ONLY:
41231
14. WATER ZONES
FROM
TO
DESCRIPTION
5
ft.
16.5
Surficial
ft.
ft
15. OUTER CASING (for multi -cased wells) OR LINER(if ap ea 11 bic)
FROM
+3 ft
TO
1.5 ft
DIAMETER
2
in.
THICKNESS MATERIAL
SCH-40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
in.
ft.
ft
ID.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
1.5 it
16.5 ft
2
In
0.010
SCH-40
PVC
ft.
ft
in
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
1
IL
Bentonite
Poured
ft
ft
f4
f4
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1
ft
16.5 f
Coarse Sand
Poured
20. DRILLING LOG (attach additional sheets if nee ssary)
FROM
ft
TO
FL
ft
DESCRIPTION (color, hardness, soil rock type, grain size, etc)
See attahced.
ft.
ft
ft.
ft
ft
ft
ft
ft
ft
21. REMARKS
ft
op 1 2013
3
WATER 0UA1 ITV SECTIONUNIT
Form GW-I
North Carolina Department of Environment and Natural Resources -D
ion of Water Quality Revised Jan. 2013