415166_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Donald H. Cummings Jr.
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. Counn•, State, Variance, etc)
3. Well Use (cheek well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
Dlrrigation
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring °Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
:Experimental Technology
OGeothennal (Closed Loop)
:Geothermal (Heating/Cooling Return)
°Groundwater Rernediation
❑ Salinity Barrier
oStormw•ater Drainage
❑Subsidence Control
:Tracer
❑Other (explain under 421 Remarks)
4. Date Well(s) Completed: 08/02/2013 Well ID# Irrigation
5a. Well Location:
Earl House
Facility/Owner Name
412 Emerald Lane
N/A
Facility IDS/ (if applicable)
Physical Address, City, and Zip
Onslow
025356
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one rat/long is sufficient
34, 33, 53.17 N 77 23 04.49
6. Is (are) the well(s): ©Permanent or :Temporary
7. Is this a repair to an existing well: :Yes or °No
Ifrh& & a repair, fill out known well construction information and explain the nature of the
repair tinder 3421 remarks section or on the back ofthis,jo'n.
8. Number of wells constructed: 1
For multiple injection or non-voter supp(r cells ONLY with the same construction, you can
submit one form.
9. Total ell depth below land surface: 118
wur
For multiple wells list all depths ifdifferent (example- 3@200' and 2©100')
10. Static water level below top of casing: 5
If water level is above casing, use "+"
77/8
11. Borehole diameter: (in.)
12. Well construction method: Mud Rotary
(ft.)
(ft)
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:
4151A6
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft.
ft
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DAMETER
THICKNESS MATERIAL
0 ft
98 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
98 ft
118 ft
4 in.
.020
Sch40
PVC
ft
ft.
in
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
93 ft
118 it
Sand
Poured
ft.
ft
20. DRILLING
LOG (attach additional sheets if nec ssarv)
FROM
TO
DESCRIPTION (color. hardness, soil/rock type. grain size. etc)
0 ft.
60 ft.
Sand
ft
n.
Void at 40'
60 ft
98 ft
Limestone with clay & sands
98 ft
118 ft
Limestone
re.
rt.
ft
ft.
ft
ft
21.REMARKS dry" rl 7Q�3
J
MU a d c
U
)A: B 1YSECS ON
a o riV'3., t y" . i�r t2;b()K�'-rS9-1. 3[s DI
FOR WATER SUPPLY WELLS ONLY:
Method of test: Air lift
l3a. Yield (gpm) 20
13b. Disinfection type: HTH Amount: 3Q(a�10%
22. Certification:
Signature of Certified Well Contractor - al Date
By signing this form, I hereby <crrifi, that the well(s) was (mere) consovcted in accordance
with 1SA NCAC 02C.0100 or I5A 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 pros?' de additional well site details or well
oonstruction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
CEN
24a. For All Wells: Submit this form .3 thinAf s DJco on SY'eil
construction to the following: "`" �s^ +-°��
Division of Water Quality, Itlfo�rmotion Processing Unit,
1617 Mall Service Center, ----
24b. For Iniection 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 of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply d Iniection 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 constmetion to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan. 2013