410456_Well Construction - GW1_20131231

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2082
1. WELL CONTRACTOR:
Sanford Sweetina
Well Contractor (Individual) Name
Coastal Geothermal
Well Contractor Company Name
102 Middle St
. Street Address
Jacksonville
City or Town
( 910) 353-0926
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10800310
OTHER ASSOCIATED PERMIT#(if applicable) n/a
NC 28546
State Zip Code
SITE WELL ID #(if applicable) n/a
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 11-28-12
TIME COMPLETED 4:00 AM ❑ PM Ut
4. WELL LOCATION:
cI7Y: North Topsail Beach COUNTY Onslow
141 South Permuda Wvnd
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
❑Slope DValley 121Flat
LATITUDE 36
LONGITUDE 75
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Ridge ❑Other
"DMS OR 3X.XXXXXXXXX DD
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: OOPS i]ropographic map
(location of well must be shown on a USGS topo map andattached to
this form ifnot using GPS)
5. WELL OWNER
Bob & Susan Frank
Owner Name
5828 Bayberry Ln.
Street Address
Raleiah NC 27612
City or Town State Zip Code
[phone]
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 205'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO MI
c. WATER LEVEL Below Top of Casing: n/a FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS n/a FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): n/a METHOD OF TEST n/a
f. DISINFECTION: Type n/a Amount n/a
4I*),t.6
g. WATER ZONES (depth):
Top n/a Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 205' Ft. Bentonite pump/tremie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top n/a Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
000' / 020' Sand & Shells
020' / 145' Silty Sand
145' / 205' Limestone
/
/
DEC 1 1- 2012
12. REMARKS: .. ---
Drilled 2-205' bore holes set .75" geothermai'iooa in each
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROV ■ r TO THE WE • NE
12.03-2012
SIG TURE •F CERTIFIED WELL + ONTRACTOR DATE i.
C L'
Sanford Sweeting FIST I 2013
PRINTED NAME OF PERSON CONS)iRUC I H WELL
4 (
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09