403328_Well Construction - GW1_20120305

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MAR 0 5 2012
r ESIDENTIAL
North Carolina Department of Environment and Natural Resources- Division/pof �141ater ua
WELL CONTRACTOR 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.
Street Address
Hampstead NC 28443
City or Town State Zip Code
( 910) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WP0290644
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply Rfr
DATE DRILLED 02/14/12
TIME COMPLETED 4:00 AM ❑ PM I3(
4. WELL LOCATION:
CITY: Wilminaton
525 Creekwood Rd.
COUNTY New Han.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope :Walley VFlat DRidge ❑Other
LATITUDE 34 is 25.6300 " DMS OR DD
LONGITUDE 77 ° 45 . 55.1100 " DMS OR DD
Latitude/longitude source: E 3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Ron Smith
Owner Name
525 Creekwood Rd.
Street Address
Wilminaton NC 28411
City or Town State Zip Code
(910 ) 686-7233
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 85'
b. DOES WELL REPLACE EXISTING WELL? YES d NO ❑
c. WATER LEVEL Below Top of Casing: 18' FT.
(Use "+" if Above Top of Casing)
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): 50 METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3a(10%
•
.
•
.
•
.
•
.
:
. Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
•
.
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Diameter
7. CASING: Depth
Top +1.5 Bottom 70' Ft. 4"
•
Top Bottom Ft.
•
Top Bottom Ft.
•
•
•
.
•
•
•
•
8. GROUT: Depth
Top 0 Bottom 22'
Material
Ft. Bentonite
Thickness/
Weight Material
SCH4o PVC
•: Top Bottom Ft.
. • Top Bottom Ft.
•
.
Diameter Slot Size
•
• Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
•
• Top Bottom Ft. in. in.
Method
Tremmie
9. SCREEN: Depth
10. SAND/GRAVEL PACK:
Depth
Material
Size Material
11. DRILLING LOG
Top Bottom Formation Description
0' / 20' Sandy clay
20' /85' Limestone
12. REMARKS:
•
FFB 2 9 Z012
WATER QUALITY SECTION
INFORMATION PROCESSING MT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OFATHIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER". ;.
JAVA02/14/12
SIgIT'ATURE OF CERTIFIED WELL CONTRACTOR DATE
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
1617 Mail Se .vice :Center,
hrnit iith:in ® comp ethhn:.W.
aleigh, NC 276
Form GW-1 a
Rev. 2/09