411228_Well Construction - GW1_20130204

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2082
1. WELL CONTRACTOR:
Sanford Sweetino
Well Contractor (Individual) Name
Coastal Geothermal
Well Contractor Company Name
102 Middle St.
Street Address
Jacksonville
NC 28645
City or Town State Zip Code
[phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# WI0800312
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ifapplicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation0 Other Me list use) Geothermal LooD
DATE DRILLED 1 1-26-12
4. WELL LOCATION:
M-435 Camp Johnson
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Camp Leieune
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley p(Flat DRidge
LATITUDE 36 "
LONGITUDE 75
cowry Onslow
(check appropriate box)
❑Other
" DMS OR 3X.XX)XXXXXX DD
" DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS Qropographic 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.)
BEO M-435
Facility Name Facility ID# (if applicable)
Cam° Johnson
Street Address
Cam) Leieune
City or Town
Carl H Baker
Contact Name
Blda 1005 Michael Rd
Mailing Address
Camp Leieune
City or Town
( 9105 451-2213
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 255'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO El
NC 28547
State Zip Code
NC 28547
State Zip Code
c. WATER LEVEL Below Top of Casing: n/a
(Use "+" if Above Top of Casing)
n'1'228
d. TOP OF CASING IS n/a 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
f. DISINFECTION: Type n/a Amount
g. WATER ZONES (depth):
Top n/a Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 255' Ft. Bentonite
Top Bottom Ft.
Top Bottom Ft.
Method
PumD
9. SCREEN: Depth Diameter Slot Size Material
Top n/a Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
in. in.
in. ' in.
in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top n/a Bottom
Top Bottom
Ft.
Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
000 / 020
020 / 060
060 / 160
160 / 255
/
12. REMARKS:
•
Formation Description
Clav/Sand
Silty Sand
Sand some Silt
Limestone with sand & silt lavers
(Medium Water Content)
C IW. ZJJ
nr
vop
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECQRLZe;1RASi§EEr4pR0y1L1EB TO TH WELL OWNER.
SIGNATj,L.RE OF CERTIFIED W
11-26-12
CONTRACTOR DATE
Sanford Sweetinq
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
days of completion to: Division of Water Quality Form GW-3b
Submit within 30 p ty - Information Processing,
FT.
JA N 9 tev.2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Ia lion PIo*es..s P';r.,