414765_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY BURR
Well Contractor Name
A - 3098
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit it: WM0800989
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑irrigation
Non -Water Supply Well:
Monitoring
❑Municipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 05/22/13
5a. Well Location:
HORTON IRON & METAL
OGroundwater Remediation
OSalinity Barrier
OStormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under 821 Remarks)
Well ID8
MW-10
Facility/Owner Name Facility IN (if applicable)
2216 US HIGHWAY 421 WILMINGTON 28401
Physical Address, City, and Zip
NEW HANOVER
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 16' 05.25" N 77° 57' 15.78"
W
6. Is (are) the well(s): OPermanent or ❑Temporary
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 1121 remarks section or on the back of this form.
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: 14' 0 (ft)
For multiple wells list all depths tfdifferent (example- 3@200' and 2@100')
10. Static water level below top of casing: 4' 0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8'0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
For Internal Use ONLY:
:14: WATER ZONES `:
FROM
TO
DESCRIPTION
ft.
ft
ft
ft.
v15: OUTER
CASING (for.inulti'cased wells) OR LiNER (if'ap hcable).:
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16.;INNER: CASING'OR TUBING.(geoth'erinaldosed-loop).
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft
4.0 ft
2.0 in'
SCH 40
PVC
ft
ft.
in.
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
4.0 ft.
14.0 ft.
2.0 tn.
.010
SCH 40
PVC
ft.
ft.
in.
'
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
1.0 ft.
PORTANDBENTO.NRE
SLURRY
ft.
ft.
ft.
ft.
19: SAND/GRAVEL PACK(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft
14.0 f`
20-40
FINE SILICA SAND
ft.
ft.
20: DRILLING LOG (attach additional sheets if necessar))::c
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 ft'
2.0 ft
BROWN SAND
2.0 ft.
14.0 ft.
TAN SAND
ft.
ft.
ft.
ft.
ft.
ft
! 1 .i G
ft.
ft
'T�'.!'U.-t.�l
ft
ft
INk'rtt\II tit tiff�tr r (✓Ii)II2` 1
21:REMARKsC6: ,: -. , .. -
BENTONITE SEAL FROM 1.0 TO 3.0 FEET
22. Cer ' ,cation:
`iV40',® 06/05/13
e ofCerti T ell Contractor Date
By signing this form, I hereby certffy 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 Infection 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suy & Infection Wells:
the address(es) above, also submit one co
completion of well construction to the cou heals department of the co'pn,
where constructed. ,� U j
North Carolina Department of Environment and Natural Resources -Division of Water Quality
222013
Revised,
2013
BY: