413463_Well Construction - GW1_20130513

For Internal Use ONLY:
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
413,163
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
f.
ft
15. OUTER CASING (for multi -cased wells OR LINER Of l' bl )
FROM
+1.5 ft
TO
80
ft
DIAMETER
4
in.
appma a _
THICKNESS I MATERIAL
PVC
16. INNER. CASING OR TUBING (geothermal closed -loop)'
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
in.
ft.
in.
It. SCRE
Water Supply Well:
OAgricultural
OGeothermal (Heating/Cooling Supply)
❑ Industrial/Commeroial
aIrrigation
O Municipal/Publio
O Residential Water Supply (single)
O Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring DReoovery
Injection Well:
❑ Aquifer Recharge
DAquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
ID Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
O Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 04/24/13 Well ID#
5a. Well Location:
Ernesto Pascual
Facility/Owner Name FacilityID# (if applicable)
704 Chadwick Shores Dr., Sneads Ferry, 28460
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
N W
6. Is (are) the well(s): JPermanent or OTemporary
7. Is this a repair to an existing well: OYes or ONo
1f this is a repair, fill out known well construction information and explain the nann'e of the
repair under #21 remarks secdon or on the back of this fans.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same constru
submit one form.
9. Total well depth below land surface: 1 00
For wells list all depths fdt¢erent (example- 3@2200' and 2@100)
10. Static water level below top of casing: 12
If water level is above casing, use "+"
11. Borehole diameter: 4 Om)
12. Well construction method: Rotary
lot, you can
(B.)
(ft)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection n-pe:
Method of test:
Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
80
100 ft
4
in.
.020
PVC
ft.
in
18. GROUT::'
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft
24
ft.
Grout
Pumped
70 ft
75 ft
Bentonite
Pumped
rt
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
75 rc
100 ft
Sand
Poured
ft
20. DRILLING LOG (atia h'additional sheets if necessary)
FROM
0
ft
TO
72
ft
DESCRIPTION (color. hardness. sail/rock type, grain size, eta)
Sandy clay to clay
72 ft
100 rt.
Limestone
ft
ft.
ft.
ft.
ft
ft
21. REMARKS .'::
ft.
MAY. -8 Z013
WATER QUALITY SECTION
INFORMATION PROCESSING UNIT
22. Certification:
04/24/13
Signature of Certified Well Contracto Date
By signing this form, 1 hereby certify the se well(s) was (seer-e) 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 bank 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
construction to the following:
�'y FL:rVIEt-'.
i'
ihin30d f lion`{
AY13
days
2613
well
Division of Water Quality, IH'o'piation Processing Unit,
1617 Mail Ser vice Center, lysigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fonn within 30 days of completion of well
constmotion to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply 8- Inlection Wells: In addition to sending the fonn to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the oounty health department of the county
where constructed.
Fonn GW-1
North Carolina Department of Environment and
Natural Resources —Division of Water Quality Revised San. 2013