413441_Well Construction - GW1_20130513

WELL CONSTRUCTION REC
This form can be used for single or multiple wells
1. Well Contractor Information:
herald R. Eister
Well. Contractor Name
2394A
NC Well Contractor Certification Number
Bridger Drilling Ent., inc.,dba Carolina Drilling
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:
DAgricultural
D Geothermal (Heating/Cooling Supply)
0 Industrial/Commercial
❑ Irrigation
Non. -Water Supply 'Well:
@Monitoring
CI Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
DRecovery
Injection Wen:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
D Experimental Technology
oGeothertnal (Closed Loop)
DGeotherm.al (Heating/Cooling Return)
D Groundwater Remediation
0Salinity Barrier
0Stormwater Drainage
D Subsi dance Control
D Tracer
other (explain under #21 Remarks)
il 08, 2013
4. Date Wells Completed:
5. Well Location:
State Employee Credit Union, Retentiona Pond
Facility/Owner Name
Facility ID# (if applicable)
141 Sanders Rd, Wilmington, NC 28411
Physical Address, City, and Zip
New Hanover
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or dechnal degrees:
(if well field: one lat/long is sufficient)
34 07" 35.52" N 77 54' 05O3"
6. Is (are) the welB(s): i Permanent or DTetnporary
7. is this a" repair to an existing well: DYes or Lll io
If this is a repair,fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed;
For multiple injection or non -water s.ply wells ONLY with the sate construction, you can
submit one form.
9. Total well depth below land surface: 4.55
For multiple wells list all depths if different (example- 3(dj2.00' and 2ia)1OO')
(ft.)
10. Static water level below top of casing: NON E (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 12
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
13. FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15: OUTER CASING (for multi -cased wells) °RUINER ftf.applicab%j
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft:
4.5 ft.
4 in,
sch 40
pvc
16. INNER CASING OR TUBING (geothermal-dosedaoup)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN ... .
FROM
TO
DIAMETER
SLOT SIZE
: THICKNESS
MATERIAL
4.5 ft. 14.5
ft.
4 in.
010
sch40
pvc
ft.
ft.
in.
113.GROUT :. ':..:.........
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft'
.2 ft.
neat
in-place
ft.
ft.
ft.
ft.
19. SAiGRAVEL. PACK (if applicable)
FROM
TO '
MATERIAL
EMPLACEMENT METH{»
3 ft-
13 ft.
sand -
tremie
ft.
ft.
20- DRILLING
LOG (attach additional sheets if neeessa )
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, ere)
0 ft.
ft.
Tan and Gray sand
ft.
ft.
MAY r- ff! 2013
ft.
ft.
ft.
ft.
-INFORMATON
WATER QUALITY SFCT1ON
ft.
ft.
FROCESSNG uNiri
ft. '
ft.
21. REMARKS,4 erz.,
' iiiilAY I 1 litan
22. Certification:
Signature of Certified Well Contractor
2013
Date
By signing ibis form, 1 hereby cart(/j that the well(s) was (were) :constructed in accordance
will: ISA NCAC 02C .0100 or 15A NiC'AC 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.
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 27699-1.617
24b. For Infection Wells: In addition to sending the formal 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.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013