413438_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
George R. Bridger
Well Contractor Name
2393A
NC Well Contractor Certification Number
Bridger Drilling Ent., inc.,dba Carolina Drilling
Company Na.e
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (cheek well use):
Water Supply Well;
°A. ricultural
°Geothermal (Heating/Cooling Supply)
Industria:i/Con ereiai
tion
Non -Water Supply Well:
LJ onitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
DExperi.ental Technology
°Geothermal (Closed Loop)
D eothermal (Heating/Cooling Return)
'Dunicipai/Public
°Residential Water Supply (single)
DResidential Water Supply (share[)
DRecovery
ElGroundwater Remediation
fl Salinity Barrier
Stormwater Drainage
Subsidence Control
(Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Comleted: '‚pnuI 2, 2013
5. Well Location:
Coastal Cleaners
DSCA#650004
Facility/Owner Name Facility ID## (if applicable)
604 Shipyard Blvd, Wilmington, NC 284
Physical Address, City, and Zip
New Hanover
County Parcel Identification No, (PIN)
51. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if wcii field, one iatllong is sufficient)
34 11'28.56" N 77 56' 58.15"
6.1s (are) the weli(s): I1Permanent or IJTemporary
7,1s this a repair to an existing well: CYes or Oo
If this is a repair,, fill out kn,own well construction information and explain the nurture ofthe
repair under #21 remarks section or on the back of this, form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONS LY with the same construction, you can
submit one form,
9. Total well depth th below land surface:25
For multiple wells list all depths if d fferertt ,(example- .3,@200 and 2@IOO)
10, Static water level below top of casing:17 3
If water level is above casing use. "4- "
11. Borehole diameter: 10 (in.)
Well construction method: Auger
12. e
(Le. auger, rotary, cable, direct push., etc.)
(ft.)
(ft.)
13. FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b, Disinfection 'pc: Amount:
f4.:WATER .N
• FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
`OUTER CASING (for multi -cased -wells) OLINER (if :applicable)
FROM
ft.
TO
15
DIAMETER
2
in.
T��� .MATERIAL
pvc
sch 40
FROM 1 TO
DIAMETER
THICICNESS
MATERIAL
ft.
ft.
FROM
TO
DJAMETER
SLOT SIZE
THICKNESS
MATERIAL
15
ft.
25
ft.
2
.
010
sch40 pvc
ft.
ft.
FROM TO
0 ft.
11
ft.
MATERIAL
neat
EMPLACEMENT METHOD & AMDUN
in -place
ft. ft.
. ft.
AND/GRAVEL P
FROM t TO
( —applicable)
MATERIAL
EMPLACEMENT METHOD
13
fst.
25
ft.
sand
tremie
ft.
ft.
t1:RULING G (attach additio s ects if Decessa
FROM TO DESCRIPTION (color, :hardness, soil/rock type, grain size, ete.)
25
Tan and Gray sand
ft.
it V1
ft.
ft,
ft.
ft.
WATER QUALITYS
INFORMATION PROCESSUhr _, •
t.
22. Certification:
Si c _.Certified Well Conlrac
, 2013
Date
ling this form, .f hereby cert f % that the well(s) was (were) constructed in accordance
i#h 15A NCAC 02C .0100 or 15,1 NC.AC 02C .0200 Well Construction Slandards and ih i 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 necessa
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,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniection 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, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Geothermal Wells: in addition to sending the form to
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
where constructed.
F01 QW-i
North Carolina Department of Envi rorunent and Natural Resources — Division of Water Quality Revised Jan, 2013