413585_Well Construction - GW1_20130515

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
John E Salmon
Well Contractor (Individual) Name
Coastal Geothermal
Well Contractor Company Name
102 Middle St
Street Address
Jacksonville NC 28546
City or Town State Zip Code
( 910) 353-0926
Area code Phone number
2. WELL INFORMATION:
WELL r.ONSTRUCTION PERMIT#
0T51L Ao8OCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply ❑
DATE DRILLED 05/10/2013
TIME COMPLETED 3:30 AM ❑ PM tg
4. WELL LOCATION:
CITY: Jacksonville a COUNTY Onslow
415 Brvnn Marr Rd. Jacksonville NC 28546
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley ilFlat ❑Ridge ['Other
LATITUDE 36 " " DMS OR 3X.X00000(XXX DD
LONGITUDE 75 " DMS OR 7X.X00000XXXX DD
Latitude/longitude source: ❑GPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Diana Rashash
Owner Name
415 Brvnn Marr Rd
Street Address
Jacksonville NC 28546
City or Town State Zip Code
(910 la) 320-3023
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 200'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g
c. WATER LEVEL Below Top of Ca
(Use "+" if Above Top of
d. TOP OF CASING IS n-a
*Top of casing terminated atlor
a variance in accordance with
sing: 15
Casing)
FT.
FT. Above Land Surface"
below land surface may require
15A NCAC 2C .0118.
e. YIELD (gem): n-a METHOD OF TEST
f. DISINFECTION: Type n-a Amount n-a
g. WATER ZONES (depth):
Top n-a Bottom n-a
S€S'e
Top n-a Bottom n-a
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top n-a Bottom n-a Ft. n-a n-a n-a
Top n-a Bottom n-a Ft. n-a n-a n-a
Top n-a Bottom n-a Ft. n-a n-a n-a
8. GROUT: Depth Material Method
Top 0 Bottom 200 Ft, bentonite qr. tremie
Top Bottom Ft
lisp Bottum- Ft. -
9. SCREEN: Depth Diameter
Top n-a Bottom n-a Ft.n-a in.
Top n-a Bottom n-a Ft. n-a in. n-a in. n-a
Top n-a Bottom n-a an -a in. n-a in. n-a
Slot Size Material
n-a in. n-a
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 /5
5 /25
25 /40
40 /65
65 /70
70 /200
/
Formation Description
top soil
silty sand
baked lime stone, silt, sand
silty sand shells
clay, silty sand
lime stone, silt
MAY 1 5.mil
WATER QUALITY SECTION
INFORMATION PROCESSING UNI I
12. REMARKS:
Drilled 3 each boreholes @ 200'. Installed 3/4" geo hernial
loop. Grouted borehole from bottom.
Slow loss of water @ 70'
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.
SI$NATURE OF eCRTIFIED WELL CONTRACTOR DATE
John E. Salmon
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water.Quaiity - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-la
Rev. 2/09