410142_Well Construction - GW1_20131231

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412 A
1. WELL CONTRACTOR:
Donald H. Cumminas
Well Contractor (Individual) Name
Applied Resource Manaaement. P.C.
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Well Contractor Company Name'
Thickness/
257 Transfer Station Rd. 7. CASING: Depth Diameter Weight
Ain
• Bottom
g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
Street -Address Top +1.5 Bottom 185' Ft. 4" SCH40
Hampstead NC 28443 Top Bottom Ft.
City or Town State Zip Code Top Bottom Ft.
( 910) 270-2919
Area code Phone number : Material
2. WELL INFORMATION: � Ft. Grout
WELL CONSTRUCTION PERMIT# 12-71063 •
OTHER ASSOCIATED PERMIT#(if applicable) '
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Fe
DATE DRILLED 11/16/12
TIME COMPLETED 2:00 AM ❑ PM Ci
4. WELL LOCATION:
CITY: Winnabow COUNTY Brunswick
8570 Telearagh Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley 'Flat D Ridge ❑ Other
LATITUDE 34 ' ' "DMS OR DD
LONGITUDE 77 ' " DMS OR DD
Latitude/longitude source: RhPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Orton Plantation
Owner Name
9149 Orton Road SE
Street Address
Winnabow
City or Town
(910 ) 520-2261
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 215'
b. DOES WELL REPLACE EXISTING WELL?
8. GROUT: Depth
Top 0 Bottom 24'
Top 175' Bottom 180'
Bottom
Bottom
Material
PVC
Method
Pumped
Ft. Bentonite Pumped
Top Bottom Ft.
9. SCREEN: Depth
Top 185 Bottom 215 Ft.4"
Top Bottom Ft.
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Diameter Slot Size Material
in. .010 in. PVC
in. in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 180 Bottom 215' Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0' / 10'
10' / 55'
55' / 70'
78' /82'
82' / 98'
98' /215'
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Sand
Material
Sand
Formation Description
Blue clay with sand
Sandy clay
Limestone
Limestone and sand
Limestone
NC 28479 r y• - .�...
State Zip Code
YES ❑ NO CAI
c. WATER LEVEL Below Top of Casing: 18' FT.
(Use "+" if Above Top of Casing)
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 3a( 10%
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12. REMARKS:
(:T - .d .. ill
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DEC 9 2012,
411Winatinfi Processing
DWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
: STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
11/16/12
SIGNATURE OF CERTIFIED WELL ONTRACTOR DATE
Donald H. Cummings r'r F?`<
PRINTED NAME OF PERSON CONSTRUCT1,t G,.TH,E.,WELLr
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Rev. 2/09
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