410241_Well Construction - GW1_20130114

N
ON RESIDENTIAL WELL CONSTRIUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412A
1. WELL CONTRACTOR:
Donald H. Cumminas
Well Contractor (Individual) Name
Applied Resource Manaaement, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigations( Other 0 (list use)
DATE DRILLED 11 /29/12
4. WELL LOCATION:
821 Fox Ridae Ln.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑ ValleypfFlat DRidge ❑Other
LATITUDE 34 14 57.2200 „DMS OR DD
LONGITUDE 77 0 47 , 55.7900 " DMS OR DD
Latitude/longitude source: 3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town
Laaan Homes
Contact Name
60 Greaory Rd_ Suite 1
State Zip Code
Mailing Address
Belville NC 28451
City or Town State Zip Code
( 910 ,) 367-1348
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 190'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 12'
(Use u+" if Above Top of Casing)
YES ❑ NO El
FT.
d. TOP OF CASING IS 1.5' FT. Above Land Surface*
• *Top of casing terminated at/or below land surface may require
: a variance in accordance with 15A NCAC 2C .0118.
•
e. YIELD (gpm): 80 METHOD OF TEST Airlift
▪ f. DISINFECTION: Type HTH Amount 3fjc10%
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top _ Bottom Top Bottom
: Thickness/
7. CASING: Depth Diameter Weight Material
Top 1.5'+ Bottom 140' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0' Bottom 24' Ft. Grout Poured
: Top 150' Bottom 155' Ft. Bentonite Poured
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
: Top 160' Bottom 190' Ft..010 in. 2" in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth
Top 155' Bottom 190' Ft.
Top Bottom Ft.
: Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
•
•
•
•
•
•
•
•
•
0' / 50'
50' / 120'
120' / 150'
150' / 190'
/
12. REMARKS:
Size
#2
Material
Sand
Formation Description
Sandy clay / clay
Limestone
Mud rock
Sandstone
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M/B0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
CORD HAS B N PROVIED TO THE WELL OWNER.
= SI
ATURE OF CERTIFIED WEL
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
11/29/12
TRACTOR DATE
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
BY: