414798_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A - 2345
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction pennits (i.e. Counry, 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
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
4. Date Well(s) Completed: 06/04/13 Well ID#
5a. Well Location:
RMR - 6265
IW-1
Facility/Owner Name Facility ID#I (if applicable)
2636 CASTLE HAYNE ROAD 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: tifica
(if well field, one latAong is sufficient) .V��-(�V►1,
34° 17' 27.34" N 77° 55' 14.50"
6. Is (are) the well(s): °Permanent or ❑Temporary
For Internal Use ONLY:
_i 1.. i •'
:14; WATER ZONES ':,r;P
FROM
TO
DESCRIPTION
ft.
ft.
fl.
ft.
FROM
IS>'.OUTER' CASING'(fur'mutti-cased'wells) OR LINER (if ap icabte)
TH►CRNESS MATERIAL
ft.
ft.
DIAMETER
in.
16. INNER CASING OR- TI1a1NG'(Aitit&iiii2 closed -loopy ,
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
5.0 ft.
4.0
in.
SCH 40
PVC
ft.
ft.
in.
1,173CREEIi;
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft.
25.0 ft
4.0 in.
.020
SCH 40
PVC
ft
ft.
in.
18`GROUT _
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
3.0 ft
POBTUWDBEnfOafE
SLURRY
ft.
ft
ft.
ft.
SAND/GRAVEL PACK (if applicable)",
PROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft.
25.0 fL
20-40
FINE SILICA SAND
ft
ft
20 DRILLINGiI (attach addifion`al slieeti ifriecessaiy)
FROM
0.0 ft
TO
5.0 ft
DESCRIPTION (color, hardness, soWrock rype, grain size, etc)
GRAY CLAY
5.0 ft
12.0 ft.
LIGHT GRAY CLAY
12.0 ft.
20.0 ft.
TAN SANDY CLAY
20.0 ft
25.0 ft
GOLD SAND
ft.
ft.
ft.
ft.
ft.
21.REMARKS.'
ft
vh! rOl1P,LUY SEG`i ION
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
7.7s tfiis-a repair to an existing well: DYes or 3No
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: 25.0 (ft.)
For multiple wells list all depths ifd different (example- 3@200' and 2@100')
10. Static water level below top of casing: 10.0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 10.0
11 Well construction method:
(in.)
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
Signature of Certified WeII Contractor
06/27/13
Date
By signing this form, 1 hereby cenify 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su . I & In'ectio
the address(es) above, also submit
completion of well construction to
where constructed.
North Carolina Department of Environment and Natural Resources - Division of Water Q
on oIelil g. the form to
s rm wtt 1if 30: days
cott0►J eajith2epprtr ent o devised
county
d V I„ ( �� '
is wised Jan. 2013
y of
TO