403859_Well Construction - GW1_20120206

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ONILESJDENTL4L WELL CONSTRUCTION RECORD
North Caroline DepaTtmeat of Environmc end Natural Res ouroes. Division of Water Quality
WELL CON17RACFOR CERTIFICATION # 2412
1. WELL CONTRACTOR:
Donald H. Cummings
W�eA Contractor (Individual) Name
Applied Resource Menajernent, PC
Well Contractor Company Name
STREET ADDRESS _25y Transf er Stad ed—.Q. 852�,
Hampstead NC _ 28443
City or Town State Zip Code
(Ea) 270 2919
Area code- Phone number
2. WELL INFORMA11ON:
SITE WELL ID fkilsoProlobst9
STATE WELL PERMIT* (if applicable)
DWQ or OTHER PERMIT # (If applicable)
WELL USE (Check Applicable Box) Monitoring MunidpallPubtic ❑
Industrial/Commercial 0 Agricultural ❑ Recoverya Injection
Irrigation 0 Other tJ (list use)
DATE DRILLED MAD
TIME COMPLETED 11:00 _ _ _ Am CD PM a
3. WELL LOCATION:
CITY: wllrnington _ COUNTY Hanoi
421 SIadcbeardRoad w. 20409
(Street Name, Nth, Conln ndty, 3ubdlvlssicn, Lot No., Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
a lope❑YaIIeJFlat❑Ridge00her
(check appropriate tog
LATITUDE 34° 11' 21" N
LONGITUTDS 077" 51' 23' W_
Latitude/longitude source: p GPS ❑ Topographic map
(fin of welt must be shown on a USGS topo map anti
stttecited to this limn if not usalg GPS)
4. FACILITY -is the nerve of the bux+ngxc where the wen' located,
FACILITY ID Alf applicable)
May be in degrees,
minutes, seconds or
in a decimal format
NAME OF FACILITY
STREET ADDRESS
City or Town State — Zip Code
CONTACT PERSON Robert Glrrrple & Syble Soloman
MAILING ADDRESS 421 Blackbeard Farr
Wilmington
City or Town
(910 _ ).3994200
Area code - Phone number
5 W EIL DETAILS:
a, TOTAL DEPTH: 1 so'
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing; 10 FT.
(Use "♦" if Above Top of Casing)
NC
State
MID
28409
Zip Code
.11/1110
NO Q
d. TOP OF CASING IS 1.5 FT. Above Land Surface'
*Top ceasing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 4O MET IOD OF TEST Airlift
f. DISINFECTION: 'Type arn-r , Amount 39010%_
g. WATER ZONES (depth)_
From To From To,�,_
From To From To_____
From ToFrorn To_,r___,"
6. CASING: Thickness/
Depth Diameter Weight Material
From0 To 125 Fi4" 50440 PVC
FromToFt
From To Ft.
7. GROUT: Depth Material Method
Frorn0 To 125 Ft Grout Tremmle
From ToFt.
From To FI.
8. SCREEN: Depth Diameter Slot Size . Material
From To . _ Ft In. 0.010 � PVC
From To _ Ft. in. in.
Frorn To FL,in. �In.
9. SANDIGRAVEL PACK:
Depth Size Material
From_
From
From
To Ft Coar e
ToFt.
To . Ft
10. DRILLING LOG
From To
0' 11'
Sand
Send
Formation Description
11L.., 26' Clay
26' 55'
SS' 85'
85' 12st
125' t SU'
4111111111.
11. REMARKS:
Sandy Clay
Limestone
Mud rock! clay
Sandstone
JAN 4-1.2-012.
WATER QUALITY SECTION
INFORMATION PROCESSING UNIT
100 HEREBY CERTIFY THAT THIS WELL WAS CON,9TRUCTED IN ACCORDANCE WITH
15A WAG 2C, WELL CONSTR TION STANDARDS, AND THAT A COPY Or THIS
• ' HAS BEEN ,
11
U. OWNER.
tictfglenfirligRT1F1ED WELL CONTR
--)1zici-
CTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: intonnatiotl Mgt,
1617 Mall Service Center - Raleigh, NC 276994617 Phone No. [phone] ext 6E8.
Form GW..l b
Rev. 7105
RECEIVED 01-27-'12 12:36 FROM- 9102702988
TO- NC DENS P&S P001/001