Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
414386_Well Construction - GW1_20130729
WELL CONSTRUCTION RECORD This form can be used for single or multiple wells 1. Well Contractor Information: Jeffrey A Stewart Well Contractor Name (NCWC) 2540-A NC Well Contractor Certification Number Mid -Atlantic Drilling, Inc. Company Name 2. Well Construction Permit /I: List all applicable well construction permits (i.e. County, State, Variance, etc.) 3. Well Use (check well use): Water Supply Well: ❑Agricultural ❑Geothermal (Heating/Cooling Supply) ❑Industrial/Coinmerciat O Irrigation Non -Water Supply Well: @Monitoring Injection Well: ❑Aquifer Recharge OAquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology OGeothermal (Closed Loop) OGeothermal (Heating/Cooling Return) ❑Municipal/Public OResidential Water Supply (single) OResidential Water Supply (shared) ORecovery ❑Groundwater Remediation ❑Salinky Barrier OStormwater Drainage @Subsidence Control ❑Tracer OOther (explain under #21 Remarks) 4. Weifl_ s. -Coen leteds6�1 Date _ ---- --- �� -., p - Weil :ID#-N Well Location: Lockwood Folly Golf Course Facility/Owner Name Facility ID# (if applicable) 19 Clubhouse Drive Holden Beach NC 28462 Physical Address, City, and Zip Brunswick County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 33 55 54.07 N 78 13 28.44 W 6. Is (are) the well(s): ©Permanent or @Temporary 7. Is this a repair to an existing well: OYes or ONo If this is a repair,1111 out known 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: 3 For multiple injection or non -water supply wells ONLY with the saute construction, you can submit one form. 9. Total well depth below land surface: 3@ 17(ft.) For multiple wells list all depths if different (example- 3 a 200' and 2@100') 10. Static water level below top of casing: 7' 53 ft. If water level is above casing, use "+" ( ) H. Borehole diameter: - (in.) 12. Well construction method: auger (4 14) (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: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi -cased wells) OR LINER (if applicable) FROM DIAMETER TO ft. ft. 2 in. THICKNESS sch 40 16. INNER CASING OR TUBING (geothermal closed -loop) FROM TO DIAMETER ft. ft. in. THICKNESS MATERIAL pvc MATERIAL ft. 17. SCREEN FROM ft. in. TO DIAMETER SLOT SIZE 10 ft. 17 ft. 2 in. 0.01 THICKNESS sch 40 MATERIAL PVC ft. 18. GROUT FROM 1 ft. in. ft. TO 3 ft. MATERIAL bentonite EMPLACEMENT METHOD & AMOUNT pour 0 ft. 1 ft concrete pour ft. ft. 19. SAND/GRAVEL PACK (if applicable) FROM MATERIAL 3 ft. TO 17 ft. torpedo EMPLACEMENT METHOD ft. ft. • pour 20. DRILLING LOG (attach additional sheets .if necessary) FROM DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) 0 Orange and tan fine- and medium -grained quartz sand ft, ft. ft. TO 17 ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS ft. i5^ �.�, a is93IO �d N,1 ,;,)Pm ,•F fe' Ni ; tfi 22. Certification: 0- ill') • fiat Well Contractor 7/15/2013 Date By signing this Arm, 1 hereby cernh' 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 16.17._ 24b. For Infection Wells: In addition to sendin above, also submit a copy of this form wr construction to the following: the ovrnktl;tddresra 3E)-gays4 ttol ipl' onY; •S 7 Division of Water Quality, Undergrou, j n.e ULC06:4trcio.,� � J 1636 Mail Service Center, RaIei "h, NC 27699-1636 24c. For Water Sunni), & Infection Wells: e cjition to sending e a o--- the address(es) above, also submit one co p�'ME'" �� ' 1Yform�zthln30_daysof completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013