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HomeMy WebLinkAboutWQ0035809_MW-4, MW-5 & MW-6_20230126WELL CONSTRUCTION RECORD F-1 1. Well Contractor Information: rLE Stephen L. Clark Well Contractor Name 2069A NC Well Contractor Certification Number The Clark Group Company Name NA 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc) 3. Well Use (check well use): Water Supply Well: (Heating/Cooling Supply) Non -Water Supply Well: Recharge Storage and Recovery Aquifer Test Experimental Technology Geothermal (Closed Loop) Geothermal (Heating/Cool QMunicipal/Public Residential Water Supply (single) Residential Water Supply (shared) [] Groundwater Remediation Salinity Barrier []Stormwater Drainage []Subsidence Control [] Tracer under#21 4. Date Well(s) Completed:12/5/18 Well ID# MW4 5a. Well Location: Stateside Wastewater Plant Facility/Owner Name Facility ID# (if applicable) Old North State Water Company Physical Address, City, and Zip Stateside Wastewater Plant. Richlands, NC/OnslowCounty 445103308576 County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field, one lat/long is sufficient) 34-52-47.39 N 77-28-47.09 6. Is(are) the well(s)E)Permanent or []Temporary 14. WATER ZONES FROM TO DESCRIPTION 7 ft- 20 ft. Surficial Groundwater ft. ft. 15. OUTER CASING for multi -cased wells OR LINER if a licable FROM TO of NIETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING(geothermal closed -loop) FROM TO DIAMETER THICKNESS MATERIAL 0 ft- 1.5 ft. 2 '"' Soh 40 PVC ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 1.5 ft. 19.5 ft- 2 in* 0.010 Soh 40 PVC ft. ft. in. 18. GROUT FROM TO MATERIAL EMPLACEMENT METHOD & ANIOFR 0 ft. 0.5 ft- Neat Cement In -Place ft. ft. ft. ft. 19. SAND/GRAVEL PACK if applicable) FROM TO MATERIAL EMPLACEMENT METHOD 1.0 ft- 19.5 ft. Coarse Sand Pour ft. ft. 20. DRILLING LOG attach additional sheets if necessary) FRODI TO DESCRIPTION color, hardness, soil/rack type, grain sin, etc. ft. ft. Attached ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: W Signature of0ertified Well Contractor 7. Is this a repair to an existing well: []Yes or []No If this is a repair, fill out known well construction information and explain the nature of the repair under 921 remarks section or on the back of this forn+. 8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells drilled: 9. Total well depth below land surface: 19.5 For multiple wells list all depths if different (example- 3 a 200' and 2@100') 10. Static water level below top of casing: 7+/ (ft.) If water level is above casing, me "+" 11.Borehole diameter: 8•5 (in.) 12. Well construction method: Hollow Stem Auger (i.e. auger, rotary, cable, direct push, etc.) 12/13/18 vate By signing this form, I hereby certify that the well(s) was (were) 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 back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTRUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636 13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b. Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 P*.\OOODRAFTING\OOODRAFFING\FIGURES TEMPLATESWONITO RING WELLS.dwq, 12/13/2018 11:48:09 AM MW4 PVC STAND—UP WELL SHIELD 2.0 FT. Lu co UZI 0.5 FT. �s 9. 0 FT. 0.5 FT. ca 1.0 FT. Z .6 ":c Ln PVC SLIP CAP LOCKING WELL CAP —CONCRETE CROWN GROUND SURFACE BENTONITE Lu (/) 1.5 FT. I 2 IN. SCH. 40 PVC RISER ........ .......... ........ .......... WATER V TABLE . .......... .......... cr 18.0 FT. .. ......... .. ......... Q) .. ......... SAND PACK V) .... .......... .......... 2 IN. SCH. 40 . ..... PVC SCREEN BOTTOM PLUG ................ AS -BUILT WELL DETAIL r SM-1 9 9 THE CLARK STATESIDE WASTEWATER DRAWN BY:CDH GROUP DISPOSAL SITE DATE: 12/13/18 4918 WRIGHTSVILLE AVENUE- WILMINGTON NC 28403 RICHLANDS, NC TELEPHONE (910)392.5555 FACSIMILE (910)392.5552 www,clarkgroup.us CLARK PROJECT NO. I I I 1513 NOT TO SCALE email: contactus@clarkgroup.us I Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1. Well Contractor Information: Stephen L. Clark Well Contractor Name 2069A NC Well Contractor Certification Number The Clark Group Company Name N 2. Well Construction Permit #: " List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) 3. Well Use (check well use): Water Supply Well: Geothermal (Heating/Cooling Supply) Industrial/Commercial C]MunicipaVPublic Residential Water Supply (single) Residential Water Supply (shared) Non -Water Supply Well: X Monitoring ©Recovery Aquifer Recharge Aquifer Storage and Recovery Aquifer Test Experimental Technology Geothermal (Closed Loop) Geothermal (Heating/Cooling ©Groundwater Remediation Salinity Barrier nStormwater Drainage OSubsidence Control ® Tracer under #21 12/5/1 8 Well ID# MW5 4. Date Well(s) Completed: 5a. Well Location: Stateside Wastewater Plant Facility/Owner Name Facility ID# (if applicable) Old North State Water Company Physical Address, City, and Zip Stateside Wastemter Plant Richlands, Nclonslow County 445103308576 County Parcel Identification No. (PIN) Sb L ft d d l 't d' d /' t/ d d 'm I d rem 14. WATER ZONES FROM TO DESCRIPTION 7 ft. 20 ft. Surficial Groundwater ft. ft. 15.OUTER CASING for multi -cased wells OR LINER if a livable FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed -loop) FRONT TO DIAMETER THICKNESS MATERIAL 0 ft. 2.0 ft- 2 in. Sch 40 PVC ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 2.0 ft 20.0 ft- 2 in. 0.010 Sch 40 PVC ft. ft. in. 18. GROUT FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT' 0 ft. 0.5 ft' Neat Cement In -Place ft. ft. ft. ft. 19. SAND/GRAVEL PACK if applicable) FROM TO MATERIAL EMPLACEMENT METHOD 1.0 ft. 20.0- ft- Coarse Sand Pour ft. ft. 20. DRILLING LOG attach additional sheets if necessary) FROM TO DESCRIPTION color, hardness, soulrock e, rain size, etc. ft. rt. Attached ft. ft. ft. ft. ft, ft. ft. ft. ft. ft. ft. ft. 21. REMARKS . a g u can ongl It e m egrees m nu es secon s or ecr a 6. Is(are) the well(s)EX Permanent or Temporary Signature of Certified Well Contractor Date 7. Is this a repair to an existing well: QYes or nXNo If this is a repair, fill out known well construction information and explain the nature oflhe repair under 921 remarks section or on the back of this fornn. 8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells 9. Total well depth below land surface: 20 (ft.) For nudtiple wells list all depths if different (example- 3@200' and 2@100') 10. Static water level below top of casing: 7+/ If water level is above casing, use "+" 11. Borehole diameter: 8•5 (in.) 12. Well construction method: Hollow Steal Auger (i.e. auger, rotary, cable, direct push, etc.) By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 [Yell 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. 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636 13a. Yield (gpm) Method of test: 24c. For Water SuoDly & Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b. Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 P.\OOODRAFTING\OOODRAFFING\FIGURES TEMPLATESWONITOMNG W ELLS.dwq, 12/13/2018 11:50:52 AM MW5 PVC STAND-UP WELL SHIELD PVC SLIP CAP LOCKING WELL CAP CL 2.0 FT. Y U CONCRETE CROWN GROUND SURFACE J m UZI 0.5 FT. Zw W U U 9.0+/- FT. o 0.5 FT. o __ 8 _ - ' BENTONITE (w,) 2.0 FT. z W o 1.0 FT. m Q� 2 IN. SCH. 40 ........ :; ;:;, I PVC RISER ......... ,r 1 r I�.' WATER TABLE — — — — — — :,,,',--------- 18.0 FT. SAND PACK ,,,, 2 IN. SCH. 40 PVC SCREEN BOTTOM PLUG ... AS -BUILT WELL DETAIL f W 0 20.0 FT. J 9 THE CLARK STATESIDE WASTEWATER DRAWN BY: 19 CDH GROUP DISPOSAL SITE DATE: 12/13/18 4918 WRIGHTSVILLE AVENUE- WILMINGTON NC 29103 RICHLANDS, NC TELEPHONE (910)392.5555 FACSIMILE (910)392.5552 www.clarkgroup.us CLARK PROJECT NO. 11115B NOT TO SCALE email: contactus@clarkgroup.uc WELL CONSTRUCTION RECORD (GW-1) 1. Well Contractor Information: Stephen L. Clark Well Contractor Name 2069A NC Well Contractor Certification Number The Clark Group Company Name NA 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) 3. Well Use (check well use): ter (Heating/Cooling Supply) Non -Water Supply Well: Aquifer Recharge Aquifer Storage and Recovery Aquifer Test Experimental Technology Geothermal (Closed Loop) Geothermal (Heating/Cooling 4. Date Well(s) Completed: 12/5/1 8 5a. Well Location: Stateside Wastewater Plant []Municipal/Public ©Residential Water Supply (single) Residential Water Supply (shared) QGroundwater Remediation []Salinity Barrier [] Stormwater Drainage Subsidence Control Tracer under #21 Well ID# MW6 Facility/Owner Name Facility ID# (if applicable) Old North State Water Company Physical Address, City, and Zip Stateside Wastewater Plant Richlands, NC/Onsim County 445103308576 County Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field, one lat/long is sufficient) 34-52-47.39 N 77-28-47.09 W 6. Is(are) the well(s)EX Permanent or Temporary 7. Is this a repair to an existing well: []Yes or E)No If this is a repair, fill out known well construction information and explain the nature of the repair under 921 remarks section or on the back of this form. 8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells drilled: 9. Total well depth below land surface: 11 For multiple wells list all depths if different (exannple- 3 a 200' and 2@100') 10. Static water level below top of casing: 2+/ If water level is above casing, use "+" I I. Borehole diameter: 8.5 (in.) 12. Well construction method: Hollow Stern Auger (i.e. auger, rotary, cable, direct push, etc.) 14. WATER ZONES FROM TO DESCRIPTION 2 ft. 11 ft. Surficial Groundwater ft. ft. 15.OUTER CASING for multi -cased wells OR LINER if a licable FROM TO DIAMETER THICKNESS NATERIAL ft. I ft. I in. 16. INNER CASING OR TUBING(geothermal closed -loop) FROM TO DIAMETER THICKNESS MATERIAL 0 ft. 1.0 ft- 2 in. Sch 40 PVC ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS NIATERWL 1.0 ft' 11.0 ft' 2 in. 0.010 Sch 40 PVC ft. ft. in. 18. GROUT FRONI TO MATERIAL ENIPLACENIENT NIETHOD & AIIIOUNT 0 ft- 0.25 ft' Neat Cement In -Place ft. ft. ft. ft. 19. SAND/GRAVEL PACK if applicable) FROM TO MATERIAL ENIPLACEMENT NIETHOD 0.5 ft. 11.0 ft- Coarse Sand Pour ft. ft. 20. DRILLING LOG attach additional sheets if necessary) FRONT TO DESCRIPTION color, hardness, soil/rock type, grain size, etc. ft. ft. Attached ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: 12/13/18 Signature of Certified ell Contractor Date By signing this form, 1 hereby certify that the wells) was (here) constructed in accordance with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constniction 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 INSTRUCTIONS (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well construction to the following: (ft.) Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Iniection Wells: In addition to sending the form to the address in 24a above, also submit one copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636 13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b. Disinfection type: Amount: completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 THE CLARK GROUP BORING LOG PROJECT NAME: Stateside Wastewater Disposal Site WELL NO. MW6 LOCATION: Richlands, NC DATE: 12/4/18 CLARK PROJECT NO: 11115B LOGGED BY: S. Clark DEPTH FROM TO DESCRIPTION (ft BGS) (ft BGS) 0 1 Brown/black organic SAND, becoming gray 1 6.5 Gray silty SAND, wet at —2 feet 6.5 11 Gray silty SAND NOTE: ft BGS REPRESENTS FEET BELOW GROUND SURFACE THE CLARK GROUP P:\OOODRAFfING\OOODRAFIING\FIGURES TEMPLATESWONITORING WELLS.dwo. 12/13/201811:54:11 AM MW6 PVC STAND—UP PVC SLIP CAP WELL SHIELD LOCKING WELL CAP Q_ 2.0 FT. Y U CONCRETE CROWN GROUND SURFACE w 0.25 FT. w U U FW— -- --- 4.0+/— FT. o 0.25 FT. BENTONITE (;� 1.0 FT. z m -- -- L z lil ...,:,:.: :.:, 0W 0. 5 FT. Q ca =........=' W U2 IN. SCH. 40 ';:? PVC RISER o •1 CL 0 11.0 FT. '. . ;;;;: ? WATER V TABLE ---- ---- --- _ it� .. _--- z cr 10.0 FT. SAND PACK-•;.;.' :::_..t cUn 2 IN. SCH. 40 PVC SCREEN BOTTOM PLUG --`"'' .......................... I Qw AS -BUILT WELL DETAIL 19 THE CLARK STATESIDE WASTEWATER DRAWN BY: CDH GROUP DISPOSAL SITE DATE: 12/13/18 4918 WRIGHTSVILLE AVENUE. WILMINGTON NC 28403 RICHLANDS, NC TELEPHONE (910)392.5555 FACSIMILE (910)392.5552 www.clarkgroup.us CLARK PROJECT NO. 11115B NOT TO SCALE email: contactus@clarkgroup.us