414388_Well Construction - GW1_20130620

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
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 #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
DGeothermal (Heating/Cooling Supply)
D Ind ustrial/Commercial
D Irrigation
❑Municipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
D✓ Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
DGeothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s)Completed: 6/26/13
5a ielr-Loca ion: -- Lockwood Folly Golf Course
❑Groundwater Remediation
DSalinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
DTracer
DOther (explain under #21 Remarks)
Well ID# MW-1
Facility/Owner Name Facility 1D# (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
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or E 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.
8. Number of wells constructed: 3
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:
For multiple wells list all depths i .different (example- 3@200' and 2@100')
3@17
(ft.)
10. Static water level below top of casing: 8.13 (ft.)
If water level is above casing, use "+"
11. ore tie.. WA -me -fee:- (in.)
12. Well construction method: auger (4 1 /4)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING1for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
2 in.
sch 40
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
12 ft.
17 ft,
2 in.
0.01
_
sch 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
1 ft.
3 ft
bentonite
pour
0 ft.
1 ft.
concrete
pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3 ft.
17 ft•
torpedo
. pour
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM ,
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
17 ft;
Orange and tan fine- and medium -grained
ft.
ft.
quartz sand
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
.! _
. !di 7 :� :"
;rs.t
ft.
ft.
,.
21. REMARKS ,r'l- t `}MAT.ti)t ,Rotf :. ''c ' fur,
,E-c 'tJ( i i!-r
22-certif.
cation:
1.' of tertied Well Contractor
i
7/15/2013
Date
y signing this form, I hereby certfr that the well(s) was (were) constructed in accordance
with 1 5A 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 We1Is: In addition to sending the form to the addres
above, also submit a copy of this form within 30 days of conpleo`"
construction to the following:
Division of Water Quality, Underground In
1636 Mail Service Center, Raleigh, IS
on,Control Poio4al,
27699 E 6,
�'
n�
24c. For Water Supply & Injection Wells: In additiOhlp sending the, form t•
the address(es) above, also submit one copy of thisoin within 305....d~ays of
completion of well construction to the county health d'e rnent'of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Jan. 2013