412906_Well Construction - GW1_20130416

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Don Cummings
Well Contractor Name
2412A
NC Well Contractor Certification Number
Applied Resource Management
Company Nam e
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)
D Industrial/Commercial
D Irrigation
Non -Water Supply Well:
DMonitoring
Injection Well:
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
❑Recovery
❑ Aquifer Recharge
D Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 03/19/13 `Jell ID#
5a. Well Location:
Marjorie Krug
Facility/Owner Name
DGroundwater Remediation
DSalinity Barrier
D Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
Facility ID# (if applicable)
217 Brookwood Ave., Wilmington, NC 28405
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)
6. Is (are) the well(s): ©Permanent or DTemporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out blown well construction information and explain the nature of the
repair under #21 remarks' section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below !arid surface: 53 ft:
For multiple wells list all depths if different (example- 3@200' and 2@100') ( )
10. Static water level below top of casing: 5.5 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 WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
412906
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable) <.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1 ft.
33 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
33 ft.
53 ft
4 in'
.010
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
20 ft.
Bentonite
Poured
ft.
ft
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
30 ft•
53 ft.
Sand
Poured
ft.
ft.
20. DRILLING
LOG (attach
additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft-
13 ft
Brn sandy clay
13 ft.
32 ft
Very hard limestone rock
32 ft•
55 ft.
Sandy limestone
55 ft.
60 ft'
Gray silty sands
ft.
ft
ft
ft
ft.
ft.
APE')
21 REMARKS 1G62013
WATER
QUALIFI. SJG I �t
INFORMATION ppOcE it b'IM
22. Certification:
03/19/13
Signature of Certified Well CDate
By signing this form, 1 hereby tern at the wells) 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
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 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, ,Raleig , k , , ` ' 1 b`
h �tC_2�7699,`.163G
24c. For Water Supply & Injection Wells: In addition to sending the farm to
the address(es) above, also submit 'one co s6L this to in 301 days of
completion of well construction to ' ` Fe
the count !heal = de�a t of; t6e county
where r ,
constructed. ``, ':" . �
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Revised Jan. 2013