403634_Well Construction - GW1_20120206

Latitude/longitude source: 1213PS ❑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 State Zip Code
Al Fulford Heating & Air
Contact Name
3461 Holden Beach Rd. SW
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 ❑ NO ICI
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
A[OI\TRESIDENTIAL WELL CONSTRUCTION RECORD 4 \IP
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 NC 28443
City or Town State Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) LOOP 3
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0
Irrigation❑ Other Ci(list 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 couNTYNew Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
DSlope ❑ Valley (Flat ❑ Ridge ❑ Other
LATITUDE 34 ° 11 47.7700
" DMS OR DD : Top Bottom
LONGITUDE 77 ° 49 ' 51.3500 " DMS OR DD
Top Bottom
T• op Bottom
.4 0 3, 6.3.4
: 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 METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
: g. WATER ZONES (depth):
: Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
. Thickness/
i 7. CASING: Depth Diameter Weight Material
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 250
Top Bottom
Top Bottom
Material
Ft. Thermex
Ft.
Ft.
Method
Tremmie
9. SCREEN: Depth Diameter Slot Size Mate
: Top Bottom Ft. in. in.
i Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Ft.
Ft.
Ft.
• 11. DRILLING LOG
: Top Bottom Formation Description
0' / 25' Silty sands
25' / 50' Clay / shell
50' / 80' Limestone
80' / 140' Clay mudrock
140' / 245' Sandstone
245' / 260' Silty clay
12. REMARKS:
1" geothermal HDPE Loop installed
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• RECRt I A -BEEN PRIDE T .NE—W L-1:1WNER.
•
SIGNATURE OF C
William Matthew Wig ns
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
01/26/12
RACTOR DATE
Submit within 30 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