412362_Well Construction - GW1_20130318

WELL ELL C NSTRUCTION CO
This form can be used for single or multiple wells
For Internal Use ONLY: •
41,,362
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Naine
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
OGeothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
❑Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
OMonitoring
DRecovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
D Subsidence Control
❑Tracer
OOther (explain under #21 Remarks)
4. Date Well(s) Completed: 02/07/13 Well ID#
5a. Well Location:
Steve Hall
Facility/Owner Name
500 Tibby's Ln.
Facility ID# (if applicable)
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 OTemporary
7, Is this a repair to an existing well: Dyes or 'No
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: 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: 135 (ft.)
For multiple wells list all depths if different (example- 3@200 and 2@100')
10. Static water level below top of casing: 13 (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 4
12. Well construction method: Rotary
in.)
(i.e. auger, rotary, cable, direct push, etc:)'
FOR WATER SUPPLY WELLS ONLY:
+80
13a. Yield (gpm) Method of test: Airlift
13b. Disinfection type: HTH Amount: 3g @ 1 0%
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
ft
ft.
in.
16.. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft.
150 ft
4 in.
PVC
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.
20 ft.
Bentonite
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*
40 ft.
Sandy clay
40 ft
95 ft. .
Limestone
95 ft
140 ft
Clay / mud rock
140 ft
185 ft.
Sandstone
ft.
ft.
ft.
ft.
ft.
ft.
ri
. !
21..REMARKS . , MiRi4O3
4
WATER QUALITY SECTION -r
22. Certification:
Signature of Certified Well Contracto
02/07/13
Date
By signing this form, I hereby certifi, that the 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
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, Raleigh, NC 27699-1636
.. ... ... , S ram' �.. rri c fT7ioih
24c. For Water Sunuly & Injection e�l5y�In `aditlortstofis�ertding;,tlbe to
''i mr� ;' L
the address(es) above, also submit one rcopy of this form within 301days of
completion of well construction to th.:counJAthde ent of the!county
where constructed. 8 � 1
4
f «.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality"'
.iniPT'n
7,
R vsed Jan. 2013