403346_Well Construction - GW1_20120326

AR 26 ZO1Z
N RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolin.'Department of Environment and Natural Resources- Division of Water Quality -
NTRACTOR CERTIFICATION # 2412-A
1. WELL CONTRACTOR:
Donald H. Cummings
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
: d. TOP OF CASING IS 1' 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): 50 METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3ca�10%
Street Address : g. WATER ZONES (depth):
Hampstead NC 28443 : Top Bottom Top
City or Town State Zip Code : TopBottom Top
P
(910 ) 270-2919 : Top Bottom Top
Area code Phone number
• Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight
WELL CONSTRUCTION PERMIT# : Top 0' Bottom 160' Ft. 4" sch40
Bottom
Bottom
Bottom
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation[ Other 0 (list use)
DATE DRILLED 02/27/12
4. WELL LOCATION:
606 Hollingsworth Dr.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ieFlat ❑Ridge ❑Other
LATITUDE 34 G 10 ' 43.5400 "DMS OR DD
LONGITUDE 77 ° 54 ' 12.7300 " DMS OR DD
Latitude/longitude source: VGPS ❑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
Karen Curran
Contact Name
606 Hollingsworth Dr.
State Zip Code
Mailing Address
Wilmington NC 28412
City or Town State Zip Code
( 910 ) 397-9370
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 180
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO q/
c. WATER LEVEL Below Top of Casing: 27'
(Use "+" if Above Top of Casing)
FT.
: Top
;• Top
Bottom
Bottom
Ft.
Ft.
8. GROUT: Depth Material
Top 0' Bottom 22' Ft. Grout
Top 22' Bottom 26' Ft. Bentonite
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size
Material
PVC
Method
Tremmie
Tremmie
Material
▪ Top 160' Bottom 180' Ft. 2" in. .020 in. PVC
: Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
: Top 26' Bottom 50' • Ft.
Top Bottom Ft.
Top Bottom Ft.
11• . DRILLING LOG
Sand
: Top Bottom Formation Description
•
• • 0' / 33' Sand (organic)
• 33' / 75' Clay
75' / 115' Limestone
115' / 155'
155' / 185'
12. REMARKS:
Mud rock / clay
Sandstone
WM 2 13 2012
t'� v 'lr`. .4 f a ?..+1 Y^ a •a t^ . ,_.+ U t J li y`
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STA /A �,-D D THAT A COPY OF THIS
• RECOR BEEN PROVIDED TO
•
; SIG
O ERTI
L CONTRACT
02/27/12
DATE
•
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i
•
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1 617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09