414784_Well Construction - GW1_20130715

WELL ELL C NSTRUCTION REC
This form can be used for single or multiple wells
For Internal Use ONLY:
I. Well Contractor Information:
ANNY SUMMERS
Well Contractor Name
A - 2579
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
O lndustrial/Commercial
❑Irrigation
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
©Monitoring
°Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Wells) Completed: 05/23/13
5a. Well Location:
SCOTCHMAN - 21
°Groundwater Remediation
❑Salinity Barrier
D Stormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under #21 Remarks)
Well ID## MW-2R
Facility/Owner Name Facility ID# (if applicable)
2192 OLD STAGE ROAD RIEGELWOOD 28456
Physical Address, City, and Zip
COLUMBUS
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 19' 45.77" N 78° 13' 06.42"
6. Is (are) the well(s): ®Permanent or °Temporary
7. s this a repair town existing well: °Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: '
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 13.0
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft)
10. Static water level below top of casing: 4.0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 7.0 (in.)
AUGER
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
4
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DESCRIPTION
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EMPLACEMENT METHOD & AMOUNT
FROM
- TO
MATERIAL
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2.0 ft.
PORTLANDBENTONITE
SLURRY
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13.0 ft
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FINE SILICA SAND
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5.0 ft
BROWN SAND
5.0 ft
13.0 ft.
GRAY SAND
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ft
ft.
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ft
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BENTONITE SEAL FROM 2.0 TO 2.5 FEET
22. Certification:
05/30/13
Date
By signing this form, I hereby certifi, that the well(s) was (were) .constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For AB Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Cen ei Ralei 7 •
l\ �iETd#5A TrR i r i I
24c. For Water Supply & Injection wells: in a dittorl to sending the fo to
the address(es) above, also submit $copY. tl�i fa Ain 3 s of
completion of well construction to• It . • = of " h
0 t 'b � oun � county
Pe P
where constructed. 1 . •
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Qua1i
devised Jan. 2013