414800_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
For Internal Use ONLY:
c44. WATER:ZONE5
FROM
TO
DESCRIPTION
ft
ft.
NC Well Contractor Certification Nwnber
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
ft
ft.
15. OUTER GASR4G.(fi r multi cased wells) OR-LINER'((f ap licii6le)'.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft
in.
16: 15NER CASING'ORTUBING (Reotherival?closed=loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft
5.0 ft.
4.0
in.
SCH 40
PVC
ft
ft
in.
IT SGREENzn
Water Supply Well:
DAgricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
DSubsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: 06/04/13 Well ID#
5a. Well Location:
RMR - 6265
IW-3
Facility/Owner Name Facility IDH (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:
(if well field, one lat/long is sufficient)
34° 17' 27.27" N 77° 55' 14.80" W,
6. Is (are) the well(s): RIPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or EINo
If this is o repair, fill ow known well construction information and explain the nature of the
repair under t21 remarks section or on the bock of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you con
submit one form.
9. Total well depth below land surface: 25.0
For multiple wells list all depths if 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 (in.)
AUGER
12. Well construction method:
(ft.)
(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
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft.
25.0 rut.
4.0
.020
SCH 40
PVC
ft
ft.
in.
i 18'GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 fr.
3.0 ft
PORTLAND BENTONITE
SLURRY
ft
ft.
ft.
ft.
39 ,SAND GRAVELPACK(dapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft
25.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20 p121ILINGIOGittitiaiadditionalsLeeis:iEpecessary
FROM
0.0 ft
TO
5.0 ft
DESCRIPTION (color, hardness, soil/rock type, grain are, etc)
GRAY CLAY
5.0 rut
11.0 ft.
TAN CLAY
11.0 rut
20.0 ft
BLACK SAND
20.0 ft
25.0 ft•
GRAY SAND
ft.
ft
ft
ft.
ft
ft.
it II.. .I Zt]!
BENTONITE SEAL Fk?'e Ml3#1t014/. 04/N
iiMP.:'fir:: RCCESSINGUNIT
22. Certification:
Signature of Certified Well Contractor
06/27/13
Date
By signing this form, 1 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 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 Su • 1 & In'ection Wells: I
the address(es) above, also submit one cop
completion of well construction to the coun
where constructed.
North Carolina Department of Environment and Natural Resources - Division of Water Quality
to
this form iN i d
r7 � I i3 `-
eat ett a e the cou ty.
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Revised Jiii1"2013