403632_Well Construction - GW1_20120206

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NON `: ESIDENTIAL WELL CONSTRUCTION RECORD
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 1
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection 0
Irrigation❑ Other N((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 • COUNTY New Han.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley itFlat ❑ Ridge ❑Other
LATITUDE 34 ° 11 ' 48.1700 DMS OR DD
LONGITUDE 77 49 ► 51.7000 DMS OR DD
Latitude/longitude source: QrGPS [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 Heatina & 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 0 NO �I
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
: 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/
7. CASING: Depth Diameter Weight Material
: Top Bottom Ft.
: Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0 Bottom 250
Material
Ft. Thermex
: Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth
Method
Tremmie
Diameter Slot Size Material
Top Bottom Ft. in.
Top Bottom Ft. in.
Top • Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
: Top Bottom
Top Bottom
Top Bottom
11▪ . DRILLING LOG
: Top Bottom
0' / 25'
Ft.
Ft.
Ft.
in.
in.
in.
Size Material
Formation Description
Silty sands
25' / 50' Clay / shell
50' / 80' Limestone
FL]
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LLJ
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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 STANDAfDS, AND THAT A COPY OF THIS
RECORD S BEEN P' IVI D A TO THE W LL WNER.
: } f �s 01/26/12
SIGNATURE 0 C RTIFIED EI L NTRACTOR DATE
: William Matthew Wi ins
PRINTED NAME OF PERSON CONSTRUCTING THE WELL .
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