413462_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
D Agricultural
D Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
El Irrigation
DMunicipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
DMonitoring DRecovery
Injection Well:
❑ Aquifer Recharge
D Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Teclmology
DGeothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑ Salinity Barrier
D Stormwater Drainage
❑Subsidence Control
DTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 04/05/13 Well ID#
5a. Well Location:
Kyle Stenerson
Facility/Owner Name Facility ID# (if applicable)
Humble Roots Farm off of Scott's Hill Loop
Physical Address, City, and Zip
New Hanover
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: ❑Yes or DIN
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 renzaf ks 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: 180 (ft)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 18 (ft.)
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 Intemal Use ONLY:
413462
14. WATER ZONE
FROM
TO
DESCRIPTION
ft
ft.
ft.
ft.
15.OUTER 'CASING (for multi -cased wells) OR LINER (if applicable)`
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft
160 ft
4 in.
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft.
in.
17. SCREEN
.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft
in.
ft
ft.
in.
18. GROUT
:.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
24 ft
Grout
Pumped
ft.
ft.
ft.
ft
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets: if. necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft
45 ft
Sandy clay / clay
45 ft
105 ft
Limestone
105 ft
155 ft
Clay / mudrock
155 ft
180 ft
Sandstone
ft.
ft.
ft.
ft.
ft.
ft
21 REMARKS:
MAY7D13
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
WA1ER CUM
ttfORMOTICKP-.' UNIT
04/05/13
Signature of Certified Well Contracto Date
By signing this form, I hereby cert j5 he 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
'Submitt is O wit
«i " n ►s do of well
24a. For All ells. hl ion
construction to the following:
ti AY
3 21112
Division of Water Quail Informatio ' P$o Unit,
1617 Mail Service C ` er, Raleigh, NC 27699-1617
24b. For Injection 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 & Injection 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.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Revised Jan. 2013