WI0800435_Report_20201118

WELL CONSTRUCTION RECORD
This form tens ba used for single or mWdple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Companv Name
2. Well Construction Permit #:WI0800435
List all applicable well construction permits n.. e. County, State, Variance, etc.)
3. Well Use (check well use):
[]Agricultural OMunicipal/Public
[]Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
Olndustrial/Commercial ❑Residential Water Supply (shared)
[]Aquifer Recharge
❑Groundwater Remediation
[]Aquifer Storage and Recovery
❑Salinity Barrier
OAquifer Test
❑Stonnwater Drainage
[]Experimental Technology
❑Subsidence Control
[]Geothermal (Closed Loop)
OTracer
OGeothermal(Heating/Cooling Return)
00ther(exnlainunder421 P
4. Date Well(s) Completed: 12/8/15 Well ID# N/A
59. Well Location:
Blue Coast Realty N/A
Facility/Owner Name Facility ID# (if applicable)
710 Brown Pelican Lane, Hampstead, NC 28443
Physical Address, City, and Zip
Pender
County
4202-59-2110-0000
parcel Idamific.tu n No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, ova latilong is sufficient)
34 22 19.02 N, 77 39 25.89
6. Is (are) the well(s): laPermanent or OTemporary
7. Is this a repair to an existing well: []Yes or ZINO
/fthis is a repair fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back ofthis form.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same amenmcdon, you can
submit one form.
9. Total well depth below land surface: 140 ft.)
For multiple wells list all depths ifdifferern (example- 3@200' and 2@100')
10. Static water level below top of casing: -
/f water level is above casing, use "+"
It. Borehole diameter: 0-25/6"-25-140/6"
25
12. Well construction method: Mud Rotary
(i.e. auger, rote rv, cable, direct push, etc.)
(ft-)
For Interval Use ONLY:
433062
14. WATER ZONES
FROM
TO
DESCRIPTION
fL
et.
rc
rt
I5. OUTER CASING Ifor mWticaved wells OR LINER its Htable
FROM
TO DIAMETER 'THICKNESS MATERIAL
0 fL
90 fL 4 1"• 1 SCH40 PVC
16. INNER
CASING OR TUBING eunwxgal
<Imed-Ioo
mom
TO DIAMETER
THICKNESS
MATERIAL
ft
ft n.
R.
ft. iv
17. SCREEN
FROM
TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
R.
ft.
in.
ft
0.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 rt
m
(t
fL
19. SAND/GRAVEL PACK
ifs lit e
FROM
TO
MATERIAL
EMPLACEMENT METHOD
(t.
a.
ft
fL
20. DRILLING
LOG attach
addonal ahifnecrosa
FROM
TO
N soeels
DESCRIPTIOloy hardoeas,aaiVmck nsiss,etn.
0 ft
82 ft.
Sands to clayey sands'
82 1"
140 fL
Limestone
140 ft
ft
Limestone clay
ft.
R.
ft
ft.
ft
R
=
rL
rt
.
21. REMARKS
Intormatl0n Processing Uni€
22. Ce cation:
Signature of Certified Well Contractor Date
By signing this farm, 1 hereby 'silly that the wells) was (were) constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ofthis 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 additionRecessary.
SUBMITTAL INSTUCTIOMECEIVEOCD
24a. For All Wells: Submit this form within 30 d s of completion of well
construction to the following: DEC 2 S 101
Division of Water Quality, Informaatitiotn Processing Unit,
1617 Mail Service eater' �Oejy y l�erYttttttgW1617
24b. For Infection Wells: hi addti�op,,,,.dfg�6t/d(Irg•pre mrtr�*ie address in 24a
above, also submit a copy of tWlf*g'G OTHROV 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) 100 Method of test: Airlift 24c. For Water Sunnly & Infection Wells, In addition to sending the forth to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 3%(o)10g completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonh Carolina Department ofE ivironment and Natural Resources - Division of Water Quality Revised Jan. 2013