406407_Well Construction - GW1_20120820

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412-A
1. WELL CONTRACTOR:
Donald H. Cummings
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)
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
IrrigationV Other 0 (list use)
DATE DRILLED 06/04/12
4. WELL LOCATION:
n 2
: d. TOP OF CASING IS 1.5' 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): 60 40'METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3qa10%
g. WATER ZONES (depth):
Top Bottom Top Bottom
: Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top 0' Bottom 57' Ft. 4"
Thickness/
Diameter Weight Material
sch40 PVC
: Top 0' Bottom 30' Ft. 6" sch40 PVC
Top
Bottom Ft.
8. GROUT: Depth
Top 0' Bottom 24'
Top Bottom
Top Bottom
9. SCREEN: Depth
802 Wine Cellars Circle : Top
Top
CITY: Wilmington COUNTY New Han. ; Top
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
Material
Ft. Grout
Ft.
Ft.
Method
Tremmie
Diameter Slot Size Material
Bottom Ft. in. in.
Bottom Ft. in. in.
Bottom Ft. in. in.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑ Slope :Walley elat ❑Ridge ❑Other
LATITUDE 34 ° 18 . 1.7400 " DMS OR
LONGITUDE 77 ° 46 . 19.1000 " DMS OR
Latitude/longitude source: VGPS ❑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.)
DD
DD
Facility Name Facility ID# (if applicable)
Street Address
10. SAND/GRAVEL PACK:
Depth
Top
Top
Top
11. DRILLING LOG
: Top Bottom
•
0' / 25'
•
•
City or Town State Zip Code •
Jason & Katie-lite
Contact Name
802 Wine Cellars Circle
Mailing Address
Wilmington NC 28411
City or Town State Zip Code
( 910 ) 632-3088
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 80'
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing: 22'
(Use "+" if Above Top of Casing)
YES ❑ NO q/
FT.
•
Bottom Ft.
Bottom Ft.
Bottom Ft.
Size Material
Formation Description
Sandy clay
25' / 80' Limestone
/
/
1• 2. REMARKS:
•
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RD HAS BEEN PRROVIDED TQ.ZHE WELL OWNER.
/
SIGNATURE OFERTIFIED WELL CO A CTOR�t 4
Donald H. Cummings_:; r;
• PRINTED NAME OF PERSON CONSTRUCTING THE1L
•
�a i `!'.✓' i > ^� ;§ W, ,,rgip>> t
Form GW-1 b
ubmit within 30 das of completion to: Division of Water Quality information Processing,
Y . . . .. Rev. 2/09
17 Mai Service Center, Raleigh, NC 27699-161, Phone • (919) 807.630.-