403636_Well Construction - GW1_20120206

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WELL CONSTRUCTION RECORD \ 3
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3470 A
1. WELL CONTRACTOR:
William Matthew Wiggins
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) Loop 5
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other Ci(Iist use) Geothermal Loop
DATE DRILLED 01 /26/2012
4. WELL LOCATION:
6425 Shinnwood Dr.
(Street.Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley FitFlat ❑Ridge ❑Other
LATITUDE 34 ° 11 ► 48.3900
LONGITUDE 77
° 49 , 52.0700
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: 3GPS ❑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
Al Fulford Heating & Air
Contact Name
3461 Holden Beach Rd. SW
State Zip Code
Mailing Address
SuDDIV NC 28462
City or Town State Zip Code
( 910 ) 842-6589
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 250'
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO [�
c. WATER LEVEL Below Top of Casing: N/A
(Use "+" if Above Top of Casing)
FT.
: d. TOP OF CASING IS 0 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): N/A
f. DISINFECTION: Type N/A
: g. WATER ZONES (depth):
Top Bottom Top
Top Bottom Top
Top Bottom Top
METHOD OF TEST N/A
Amount N/A
7. CASING: Depth Diameter
: Top Bottom Ft.
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Material
Top 0 Bottom 250 Ft. Thermex
: Top Bottom Ft.
Top Bottom Ft.
Bottom
Bottom
Bottom
Thickness/
Weight Material
9. SCREEN: Depth Diameter Slot Size
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
: Top Bottom Ft.
Method
Tremmie
Material
in. in.
in. in. r-----��
in. P-rui
Size Material : �J
11,11
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0' /25'
25' / 50'
50' / 80'
80' / 140'
140' / 245'
245' / 260'
Formation Description
Silty sands
Clay / shell
Limestone
CC'
CC)
LLI
LL.
ELA
1.-Z1. I ,
Clay mudrock
Sandstone
Silty clay
12. REMARKS:
1" geothermal HDPE Loop installed
tl
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND"THAT A COPY OF THIS
• RECJ/0 D HAS EEN PR VID,ED-GWN€R.l' 4 ,
• SIGNATURE OF CERTIFIED
William Matthew Wiggins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
01/26/12
TRACTOR DATE
Submit within 80 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09