WV0800230_Report_20191112

WELL CONSTRUCTION WOO" 6G M/DWR
1. Well Contractor Information:
John Salmon NOV 12 "f11
Well Contractor Name
3497-A Water Quality Regional
NC Well Contractor Certification Number Operations Section
Applied Resource
eny Name 2.WM0800230
2. Well Construction Permit q:
List all applicable irell construction permits (i.e. UIC, Coram, State, Variance, etc./
3. Well Use (check well use):
(Heating/Cooling Supply)
Non -Water Supply Well:
Recharge
Storage and Recovery
Test
rental Technology
mal (Closed Loop)
DMunicipal/Public
Residential Water Supply (single)
DResidential Water Supply (shared)
DGroundwater Remediation
DSalinity Ban ier
DStormwater Drainage
DSubsidence Control
DTracer
under#21
4. Date Wells) Completed:10/16/19 well IDS N/A
5a. Well Location:
David Ward N/A
Facility/Owner Name Facility 1DR (if applicable)
2830 Hydrangea Place, Wilmington, NC
Physical Address, City, end Zip
New Hanover
County
R05416-008-003-001
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field, one]m1long is sufficient) 22. ertifl afion• �: a��Cei'C11
34 13 0924 N 77 54 3330 W L'
- I U/10/19
�fl
�n-.,. Date
�slgi�g wells/ was (were/ constructed in accordance
7. Is this a repair to an existing well: DYes or ElNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well C'onsrrucana Standards and that a
If this is a repair fill out known well contraction information and explain the nature of rite copy of this record has been provided to the well carrier.
repair under c11 remarks section or on the back ofthis form.
f
For Internal Use Only: 462783
6. Is(are) the well(s)Ox Permanent or DTemporary
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:1
9. Total well depth below land surface: 80 (ft.)
For multiple wells list all depths fdferent(erample. 3@200'and 2@100')
10. Static water level below top of casing: 9
If nnter level is above casing, use "-"
11. Borehole diameter: 7 7/8 (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER TONES
FROM
TO
I DESCRIPTION
f.
ft.
fL
ft
15. OUTER CASING for
mWd-cased webs OR LINER ifa Ecable -
FROM
TO
DIAMETER THICKNESS MATERIAL
0 ft
55 ft-
1 4 In SCH40 PVC
16. INNER
CASING OR
TUBING embermal
closed400
FROM
TO
DIMfEI'ER
THICKNESS
MATERIAL
ft
ft.
iv.
k.
17. SCREEN
FROM
TO
DIAMETER
SLOT'SIZE
THICKNESS
MATERIAL
55 ft•
75 ft.
4 In'
.010
SCH40
PVC
ft. I
ft.
in.
18. GROUT
FROM
TO
I MATERIAL
EMPLACEMENT METHOD &AMOUNT
0 fL
52 ft-
Bentonite
Poured
ft
ft.
ft
ft.
19. SAND/GRAVEL
PACK
s applicable)
FROM
TO
I MATERIAL
EMPL4CEMENTMrvHOD
52 ft
75 ft.
Coarse
Poured
ft
R.
11
20. DRILLING
LOG factsch
additional sheets if necessary)
FROM
TO
I DESCRIPTION(color, hardness, soNrock type, grainsim eta.
0 fL
10 ft
Sand
10 ft
30 Il.
Black loamy sand
30 ft
35 ft.
Layered limestone
35 ft
75 ft.
Limestone
fL
ft.
it
ft
ws.
21. REMARKS
Nt
7)rQC`.SnLn4i nl
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:
(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) 10 Method of test: Airlift 24c. For Water Supply & luiection 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: HTH Amount: 3% @ 10g 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