411079_Well Construction - GW1_20130204

1. WELL CONTRACTOR:
Donald H. Cummings
Well Contractor (Individual) Name
Applied Resource Management. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(irapplicable)
SITE WELL ID #(If applicable) MW-12
3. WELL USE (Check One Box) Monitoring Municipal/Public ❑
IndustriaUCommercial ❑ Agricultural 0 Recovery 0 Injection 0
IrrigationD Other D (list use)
DATE DRILLED 12/12/12
4. WELL LOCATION:
Off of Hwv 50 North
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Holly Ridge COUNTY Pender
TOPOGRAPHIC / LAND SETTING:. (check appropriate box)
❑Slope ❑Valley EifFlat ❑Ridge ❑Other
LATITUDE 34 ^ 34 .28.2500 " DMS OR DD
LONGITUDE 77 > 36 . 5.4900 " DMS OR DD
Latitude/longitude source: R,GPS [Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Surf City WWTP
Facility Name Facility ID# (if applicable)
Off of Hwv 50 North
Street Address
Holly Ridoe
City or Town
L M Mcl amh and Son Inc
Contact Name
800 Mcl amh Rd
Mailing Address
Calabash NC 28467
City or Town State Zip Code
( 910 ) 443-7082
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12'
NC 28445
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO rj
c. WATER LEVEL Below Top of Casing: 5 06' FT.
(Use "+• if Above Top of Casing)
i ` ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412A
411079
d. TOP OF CASING iS 2 5' FT. Above Land Surface*
"Top of casing terminated at/or below land surface may require
a valiance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top 0' Bottom 2' Ft. 2" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material - Method
Top 0' Bottom 0.5 Ft. Grout Poured
Top 0.5 Bottom 1' Ft. Bentonite Poured
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 2' Bottom 12' Ft. 2" in. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 1' Bottom 12' Ft. #2
Top Bottom Ft.
Top Bottom Ft.
Material
Sand
11. DRILLING LOG
Top Bottom Formation Description
/ See attached
/
12. REMARKS:
titdui
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
R RD HASBEEN ROV D HE WELL OWNER.
C-MYeti 1 iL nCM 12/12/12
NATURE OF CERTIFIED WELL CONT/ ACTOR DATE
Donald H Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit Within 30 days of completion to: Division of Water Quality - Information Processing, Rev 2/09
Form GW-lb
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
RECENFD
AN 2 8 2nfl

Juniper Swamp
Surf City Waste Water Treatment Plant
Holly Ridge, NC
MW-12
Drilled By: Donald Cummings
Logged By: Joseph Zuncich
Date: 12/12/12
Depth
(ft.)
Description
Water
Content
0 - 0.5'
Dark gray, very fine sand with organic and root matter.
2' - 4'
Tan brown, silty sandy clay.
Moderate
5' - 7'
Tan brown with orange mottles, silty clay, dense.
High
10' - 12'
Light to medium gray, sandy clay, soft.
High