413518_Well Construction - GW1_20130514

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
A et
1. Well Contractor Information
Sean Cropsey
Well Contractor Name
2485
NC Well Contractor Certification Number
Skipper's Well Drilling & Pump Service, Inc.
Company Name
2. Well Construction permit #: WP0290789
List all applicable permits (Le. County, State, Variances, Etc.)
3. Well Use (check well use):
Water Supply well:
Agricultural
DGeothermal
EiIndustrial/Commercial
D Irrigation
Non -Water Supply Well
Monitoring DRecovery
OMunicipal/Public
Residential Water Supply (single)
0
Residential Water Supply(shared)
Injection Well:
DAquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Ei Aquifer Test 0Stormwater Drainage
El Experimental technology 0Subsidence
control
OGeothermal (closed Loop) ®Tracer
['Geothermal (Heating/Cooling RetugOther Explain under #21 remarks
4. Date Well (s) Completed: 04/16/13 Well ID#
5.a Well Location:
Scott Gerow
Facility/Owner Facility ID# (if applicable)
Q121 Shiloh Drive Lot 8 Section 3 Subdivision Battleoark
Physical Address, City and Zip
New Hanover
County
FROM
TO
DESCRIPTION
95 ft
115
ft
ft
ft
FROM
TO
Nfi !o► "r ui =cased:
DIAMETER THICKNESS
'IE ((ftap
MATERIAL
icehic) .,_ ... .
0 ft.
FROM
0 ft 0 in.
0
� 1
TO
QR: TUBIN
DIAMETER THICKNESS
+2 ft
95 ft
2 in.
PVC
MATERIAL
ft
FROM
TO
ft
in.
r"-+-ter t. �:.� { - .,r,.- - -) i ... y } .' �'E� �- i i � is x4 �.� � -
r! y \ 1 � 1;..__. 1�-- .L K ti, x - � „' I n_` � _._ Srtt.;`c".i ;. v _ F. ....:_-1..,. _. i ..
MATERIAL
D1AM
SLOTTHICKNESS
95 •ft
115 ft
2 in.
15
PVC
ft
ft
in.
Parcel Identification No. (PiN)
� t
f � -
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FROM TO MATERIAL 1 EMPLACEMENT METHOD & AMOUNT
Oft
3ft
3ft
20 ft
portland
bentonite grout
ft
ft
., i'-'r"}x;-�.r� �^rr.. � 3se...t�.:2'� .+t,F.f,",_ .. s.•.-,7� �, _.. ` . _..._ _ . .. ..
TO MATERIAL 1 EMPLACEMENT METHOD
FROM
85 ft
115 ft
#2
Gravel
ft
ft
FROM
0 ft.
I _.1.4,11._,Ittift,h
TO
40 ft
, 1 i ti a r_••v- ?- S
DESCRIPTION (color, hardness, soil/rock type, grain size
Sand
40 ft
45 ft
45 ft
80 ft.
90 ft
80 ft
100 ft.
115 ft
clay.
sand
soft limestone and s ejls
limestone to hard lies_
ft
ft
rE.:
ft
ft MAY 1 4 7013
`. _'-z`� r ,-}� � r � _ � -2 � C e 1 4 e_ Y J �''�l 5'7 "'+. 'i'
I, Riz._1-..Y r r".-. - t-..sr"f �., �'S. is , .'. ^,_.. .,r. .,.,.'>. ., ...ie t.:: _:�5 ._-, - .Jar.--......z-
22. Certific
5b. Latitude/Longitude in degrees/minute/seconds or decimal degrees:
(if well field, one lat/long is sufcient)
N 34° 06.993' W 077° 53.816'
6. Is (are)the wells(s): [permanent or "FEnporary
7. is this a repair to an existing well: Yes ONO a]
if this is a repair, fill out known well construction info, explain the nature of
the repair under #21 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: 115
For multiple wells list all depth if different (example- 3@ 200' and 2©100')
10• Static water level below top of casing: 18ft. 24b:.For Injection Wells: in addition to sending the form to the address in 24
if water level is above casing, use "+" 'above, also submit a copy of this form within 30 days of completion of well
11. Borehole diameter: (in.) construction to the following:
12. Well construction method: Rotary to Division of Water Quality, Underground injection Control Program
(L
e., auger, rota cable, direct push, etc.) 1636 Mail Service Center, Raleigh, NC 27699-1 636
g rotary,
FOR
WATER SUPPLY WELLS ONLY: 24c.For Water Supply & Geothermal Weils:Send this form to
13a. Yield (Gpm) Method of test: the address (es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b Disinfection type: HTH Amount Cup where constructed
ion:
"Rivii::_ijiON PROCESSING UNIT
V7( 4/ 5
Signature of Certified Well Contr r Date
By signing this , 1 hereby certify that the well (s) was (were)constructed in accordant+
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well construction standards and
that a copy of this well 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 it necessary.
24. Submittal instructions:
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,
1607 Mail Service Center, Raleigh, NC 27699-1617