412342_Well Construction - GW1_20130313

WELL CONST UCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531
NC Well Contractor Certification Number
Applied Resource Management, PC
Company Name
2. Well Construction Permit #: NA
List all applicable well construction permits (i.e. Coun y, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
5
ft
16 rt
Surficial
it.
ft.
15.OUTER CASING (for multl<asedwells) OR LINER (if ap1' bl )
FROM
+3 ft
TO
1
ft
DIAMETER
2
in.
P uee
MATERIAL
SCH-40 1 PVC
THICKNESS
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
IL
ft
ft
ft.
in
17. SCREEN
Water Supply Well:
❑Agricultural
°Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
°Municipal/Publio
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
aMonitoring °Recovery
Infection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Beating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stonmwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Dale Well(s) Completed: 2/11/13 Well ID# MW-4
Sa. Well Location:
Hampstead Town Center
Facility/Owner Name Facility lD# (if applicable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and Zip
Pender
3293-86-8315-0000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one tat/long is sufficient)
24 deg. 23' 23.65" N 77 deg. 40' 31.33"
6. Is (are) the well(s): RPermanent or °Temporary
W
7. Is this a repair to an existing well: °Yes or ENo
If this is a repair, fill out blown well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: 4
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: 16 (ft)
For multiple wells list all depths if different (example- 3Q200' and 2Q100')
10. Static water level below top of casing: 5.49 (ft)
If water level is above casing, use "A"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (um)
13b. Disinfection type:
Method of test:
Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
16 ft
2
in
0.010
SCH-40
PVC
ft
in
1&'GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
0.5 it.
Bentonite
Poured
ft.
f.
ft
ft.
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
0.5 ft
16
ft.
Coarse Sand
Poured
ft.
20. DRILLING LOG (attach additional sheets if nece sary)
FROM
TO
ft.
DESCRIPTION (color, hardness, soiVrock Vie, grain size, etc.)
See attahced.
ft
ft
ft
It.
ft
ft.
ft
ft
ft
21. REMARKS
ft
MAR . 2013
WATER (y IAI ITV SECTION
INFORMATION PROCESSING uNrr
22. Certification:
ofCertif Well Contactor°
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I5A 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 baok 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 Mall Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the farm to ,the ni address2 4a
above, also submit a copy of this form wrthmr30 d y of oo )i$fior}MoElwell
construction to the following: `""' " `1 (}
Division of Water Quality, Underground;Inj�Cotl
1636 Mail Service Center, Ralei h, 2 69 1 6 l;
�i
24c. For Water Suooie & Infection Wells: L edition to sending the form to
the address(es) above, also submit one copy. "this-fmm-wiliii 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Ian. 2013

HAMPSTEAD TOWN CENTER
1,7270 HIGHWAY 17
HAMPSTEAD, NORTH CAROLINA
MW-4
Drilled by : M. Sage
Logged by: J. Zuncich
Date: 02/11/13
Depth
(ft.)
Description
Water
Content
Blow
Count
2 - 4
Gray -brown, very fine to fine grained sand with orange
mottles, root matter and organic material. No odors.
Low to
Moderate
Grab
5 - 7
Tan -light brown, very fine grained sand with minor wood
fragments. No odor.
High
HP
10 - 12
Light gray -tan, silty to very fine grained sand with wood
fragments. No odor.
High
HP
14 - 16
Light gray -tan, silty to very fine grained sand changing to
greenish -gray, clayey sand/sandy clay mixture. No odor.
High
HP
HP = Hydraulic Push