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HomeMy WebLinkAboutWQ0040918_Other_20200217WELL CONSTRUCTION RECORD This form can be used for single or multiple wells For Internal Use ONLY: 1. Well Contractor Information: Thomas Ammons Well Contractor Name 2035A NC Well Contractor Certification Number Environmental Hydrogeological Consultants,lnc Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. County, State, Variance, etc) 3. Well Use (check well use): Water Supply Well: ❑Agricultural ❑Geothemtal (Heating/Cooling Supply) ❑ lndustrial/Commercial ❑ Irrigation Non -Water Supply Well: El Aquifer Recharge El Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ❑Geothermal (Closed Loop) ❑Geothermal (Heating/Cooling ❑Municipal/Public El Residential Water Supply (single) ❑Residential Water Supply (shared) El Groundwater Remediation ❑ Salinity Barrier ❑ Stormwater Drainage ❑Subsidence Control ❑Tracer ❑Other (explain under #21 F 4. Date Well(s) Completed: 12/19/2019 Well ID# MW-3 5a. Well Location: Ag Protein, Inc. Facility/Owner Name Facility ID# (if applicable) 420 Bonham Road, Magnolia, 28453 Physical Address, City, and Zip Duplin County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 78.119284 N 34.86216 W 6. Is (are) the well(s): ❑] Permanent or ❑Temporary 7. Is this a repair to an existing well: ❑Yes or ONo If this is a repair, fill out known well construction information and explain the nature of the repair under #21 remarks section or on the back of this form. 8. Number of wells constructed: 3 Of 4 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: 15 (ft.) For multiple wells list all depths if different (example- 3@200' and 2@100') 10. Static water level below top of casing: (ft.) If water level is above casing, use "+" 11. Borehole diameter: 6.25 (in.) 12. Well construction method: Hollow -Stem Auger (i.e. auger, rotary, cable, direct push, etc.) 14. WATER ZONES FROM TO DESCRIPTION rt. rt. ft. ft. 15. OUTER CASING for multi -cased wells OR LINER if a licable FROM TO DIAMETER THICKNESS MATERIAL 0 rt. 5 rt. 2 in. Sch.40 I PVC 16. INNER CASING OR TUBING eother a] closed -loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft ft in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL 5 ft' 15 ft' 2 in. .010 SCh.40 PVC ft. ft. in. 18. GROUT FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT 0 rt. 1 rt. Concrete Neat Cement / Stand -Up 1 rt. 4 ft- Bentonite Slow Pour Hydrated Pellets rt. rt. 19. SAND/GRAVEL PACK (if applicable) FROM TO MATERIAL EMPLACEMENT METHOD 4 ft• 15 ft. No. 2 Filter Media Slow Pour rt. rt. 20. DRILLING LOG attach additional sheets if necessary) FROM TO DESCRIPTION color, hardness, soil/rock type, grain size, etc. 0 ft- 15 ft. Fine Sand w/ Occasional Clay Inclusions rt. rt. ft. ft. rt. rt. rt. rt. ft. ft. rt. rt. 21. REMARKS 24 er ' Ica1i 02/17/2020rev S e of Certified Well Contractor Date 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 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 Service Center, Raleigh, 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 form within 30 days of completion of well construction to the following: Division of Water Quality, 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 & Injection 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 Environment and Natural Resources - Division of Water Quality Revised Jan. 2013