415170_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #:/A
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
OGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
1Irrigation
DMunicipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
OAquifer Test
DExperimental Technology
OGeothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
❑Groundwater Remediation
OSalinity Barrier
OStormwater Drainage
DSubsidence Control
OTracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 7/14/13
5a. Well Location:
S & W Home Builders
Well ID#
Facility/Owner Name Facility ID# (if applicable)
886 Hollybriar Drive SE, Bolivia, NC 28422
Physical Address, City, and Zip
Brunswick
County
184EA012
Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36, 59 N 78, 15
W
6. Is (are) the well(s): ZPermanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ©Nil
If this is a repair, fill out known well construction information ion and explain the nature o f the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For nn,rltiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 160 (ft.)
For multiple wells list all depths if different (example- 30?00' and 2(ci;100')
10. Static water level below top of casing: 5.5 (ft.)
If water level is above casing, use "-= "
11.. Borehole diameter: (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 2025 Method of test: Air lift
13b. Disinfection type: HTH Amount: 3 • Al 0%
415170
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
0 ft
160 ft.
4 in.
Sch40
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
30 ft
60 ft
4 in.
.020
Sch40
PVC
130 ft.
160 ft
4 in.
.020
Sch40
PVC
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
25 ft-
Bentonite
Poured
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
25 ft
160 ft
Sand #2
Poured
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft
15 ft
Reddish brown sandy clay & course sand mi;
15 ft
60 ft.
Sandy limestone
60 ft
130 fr.
Gray clay with rock lenses
130 ft
160 ft.
- Fine gray sand to mud rock and clay
ft.
ft.Anr;
ft.
ft.�
7flV I
ft.
ft.
rA .� `�
j i
1 ,t �� e��•��p.� �y k 4t
21. REMARKS J
22. Certification:
Signature of Ceti led Well Contractor
7/14/13
Date
By signing thisform, 1 hereby certifi; that the well(s) was (were) constructed in accordance
with 15A NC4C 02C .0100 or 15,4 NC4C 02C .0200 Well Construction Standards and that a
copy- of this record has bees 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 atta Y n(�}(j[ilit io ta1 a i e-ce
;f iJ
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this fo
construction to the following:
Division ofWater Quality, rma1ion Pr .essing Uni• —
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 ofWater Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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 counter health depai talent of the county
where constructed.
«;a
vithi
tior0 c well
Forrn GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised Jan. 2013