413461_Well Construction - GW1_20130508

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well ConnactorName
2412A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #:
List all applicable well construction permits 0.e. County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
A1`k RI1
14. WATER.ZONES
FROM
TO
DESCRIPTION
ft
rt.
ft
15. OUTER CASING (for multi -cased wells) OR LINER (d ap. isc aa bl )
FROM
+1.5 ft
To
120 ft.
DIAMETER
4
in.
P .. -.
THICKNESS 1 MATERIAL
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
°Irrigation
°Municipal/Public
°Residential Water Supply (single)
o Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring OReoovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
o Tracer
o Other (explain under #21 Remarks)
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERLSL
ft.
in.
ft
in.
18: GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
24
ft
Grout
Pumped
ft.
ft
ft
ft.
19.SAND/GRAVELPACK (if applicable)
:
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
20. DRILLING LOG (atta h additional sheets if necessary)
FROM
0
ft
TO
10
ft
DESCRIPTION (color, hardness, soil/rock type, grain she, etc.)
Sand
4. Date Well(s) Completed: 03/26/13 Well ID#
5a. Well Location:
Riptide Builder
Facility/Owner Name Facility ID# (if applicable)
148 Marina Wynd Way, Sneads Ferry, NC 28460
Physical Address, City, and Zip
Onslow
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one let/long is sufficient)
N W
6. Is (are) the well(s): °Permanent or °Temporal,'
7. Is this a repair to an existing well: °Yes or °No
If this is a repair, fill out kpoun well construction information and explain the nanny of the
repair rider #21 remarks section or on the back of this farm.
8. Number of wells constructed: 1
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: 140
For multiple wells list all depths if different (example- 3@.200' and 2@100')
(ft.)
10. Static water level below top of casing: 14 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4
12. Well construction method: Rotary
(ie. auger, rotary, cable, direct push, etc.)
10 ft
105 ft
Sandy clay / clay
105 rt
140 ft
Limestone
ft
ft
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
136. Disinfection type: Amount:
ft.
it.
ft.
ft
ft.
ft.
21. REMARKS..
MAY A S 2013
22. Certification:
WATER QUALITY SECTION
INFORMA71om na
UotSSING UNIT
03/26/13
Signature of Certified Well Contractor — Date
By signing this fonn, I hereby cerb& that t e well(s) was (were) consa'ricted in accordance
with I5A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Consnvcdon 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 Senice Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the fonn to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
contraction to the following:
Division ofM'ater Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supnk & Injection Wells: Ip addition to sending the form to
the address(es) above, also submit one copy of this fort within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment a
nd Natural Resources -Division of Water Quality Revised Ian. 2013