406961_Well Construction - GW1_20120813

ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 4145 A
1. WELL CONTRACTOR:
Christopher Blackmon
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead
City or Town
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
28443
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation Other 0 (list use)
DATE DRILLED 06/21/2012
4. WELL LOCATION:
3344 Paramount Wav
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilminaton COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
Q Slope ❑Valley elat ❑ Ridge ❑Other
LATITUDE 34
LONGITUDE 77 " DMS OR DD
" DMS OR DD
Latitude/longitude source: MPS ❑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.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town
Roaer Kueffer
State Zip Code
Contact Name
3344 Paramount Wav
Mailing Address
Wilminaton NC 28405
City or Town State Zip Code
( 443 ) 995-2632
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 95'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 54
c. WATER LEVEL Below Top of Casing: 8'
(Use "+" if Above Top of Casing)
FT.
d. TOP OF CASING IS 1 .5' FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
•
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 40+ METHOD OF TEST Airlift
f. DISINFECTION: Type HTH
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 75' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
Amount
3q( 10%
8. GROUT: Depth Material Method
Top 0' Bottom 20' Ft. Bentonite Tremmie
: Top 70 Bottom 95' Ft. Grout Tremmie
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size - Material
Top 75' Bottom 95' Ft. 2" in. .10 in. pvc
Top Bottom Ft. in. in.
Top . Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top Bottom
Top Bottom
: Top Bottom
: • 11. DRILLING LOG
Top Bottom
0 / 15'
15' / 40'
40' / 65'
65' / 100'
/
• 12. REMARKS:
Size Material
Ft.
Ft.
Ft.
Formation Description
Silty sands
Clay
Limestone
Sandstone
re.
AY; is 20",
611 �..A, ry_r.
,� PtO�j
`✓+
▪ I DO HEREBY CERTIFY THAT THIS WELL WAS CON T4z•
ACCORDANCE WITH 15A NCAC 2C, WELL CONS ` �1 -t • i ,- "v
: STANDARDS, AND THAT A COPY OF THIS RECORD HAS`BEEN
PROVI a_ D TO THE WELL OWNER.
G ATUR OF E IFIED WELL CONTRACTOR
: Christopher Blackmon
06/21/12
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
•
Form GW-lb
Rev. 2/09