414346_Well Construction - GW1_20130722

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Bobbie D Fower
Well Contractor Name Ji u t_ E 5 [Ul's
(NCWC) 2869-A Protect'
Q } I�
NC Well Contractor Certification Number AquiferP�Iect' Section
Mid -Atlantic Drilling, Inc.
RECE(VEDIDENRIDIl Q
Company Name
2. Well Construction Permit #: N/A
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)
D Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0Monitoring ❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
OGeothermal (Closed Loop)
OGeothennal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6/19/13 Well ID# MW-1
Sa. Well Location:
Pemberton Drive - 306 N/A
Facility/Owner Name Facility IN (if applicable)
306 Pemberton Drive - Wilmington NC
Physical Address, City, and Zip
New Hanover •
N/A
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34.1901063 N 77'903605
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
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 421 remarks section or an the back of this form.
8. Number of wells constructed:
For multiple injection or non -water. supply wells ONLY with the.cante construction, you can
.submit one form.
1
9. Total well depth below land surface: 16 (ft.)
For multiple wells list all depths if different (example- 30200' and 2@.100')
10. Static water level below top of casing: 9 (ft.)
If water level is above casing, use •'
11. Borehole diameter: " " 8 (in.)
12. Well construction method: auger
(i.e. auger, rotary. cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15, OUTER CASING (for multi -eased wells) OR LINER (if ap .licable)
FROM
TO
DIAMETER
THICKNESS
MATERAAI.
ft.
It.
2 in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft,
6 rt.
2 in.
sch 40
pvc
ft.
ft.
In.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
6 ft.
16 ft•
2 in.
0.01
sch 40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
2 ft'
4 ft.
bentonite
pour
0 ft.
1 ft.
concrete
pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft•
16 It
#2 torpedo sand
pour
1 ft.
2 ft.
natural pack
pour
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO DESCRIPTION (color, hardness, sod/rock type, grain size, etc.)
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Concrete pad/ w flush mount man hole cover
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection hype: Amount:
22. Certification:
,ski^ cent
Si uature of Certified Well Contractor
07/01/2013
Date
By signing this farm, 1 hereby certiikthat 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-fonn 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 flail Service Cente• h C
24c. For Water Su tl & to echo»
the address(es) above; also submit on
completion of well construction to th
where constructed.
1d1Rg t
G1rpy yyts f, np}
my fth ftpirtrai
Form GW-1
North Carolina Department of Environment and Natural Resources- Division of Water Quality BY. d Jan. 2013