414783_Well Construction - GW1_20130722

WELL CONST 'ti UCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
DANNY 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)
Olndustrial/Commercial
°Irrigation
QMunicipal/Public
❑Residential Water Supply (single)
°Residential Water Supply (shared)
Non Water Supply Well:
©Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Recovery
°Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 05/23/1 3 Well IDlS#
5a. Well Location:
SCOTCHMAN - 21
MW-10R
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/hong is sufficient)
34° 19' 45.80" N 78° 13' 05.80"
W
6. Is (are) the well(s): ©Permanent or °Temporary
7..Is this a repair to an existing well: °Yes or EINo
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 d ferent (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:
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DESCRIPTION
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DIAMETER
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THICKNESS MATERIAL
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DIAMETER
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SLOT SIZE
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THICKNESS
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EMPLACEMENT METHOD & AMOUNT
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PORTLAND BENTONITE
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13.0 ft.
20-40
FINE SILICA SAND
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DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
BROWN SAND
GRAY SAND
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BENTONITE SEALS
22. Ccation:
initt2[0121§' §FRON
PROCESSING UNIT
05/30/13
Signature of Certified Well Contractor Date
By signing this form, I hereby certf that the well(s) was (were) constructed in accordance
with_1 SA..NC.ACO2C .0100 or I SAN.CAC 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 All 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 Injection 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 Center, Ralei 1p� y
24c. For Water Supply & Injection Wells: 4&11ifiibn
the addresses also submit one co
address(es) above, p'-if thi yf
completion of well construction to the co p ty` eal -_
where constructed. �s=
I 5 4tl:ttt.���
:iS endrag the` fOri ©� �
Avi in 30 days ,k6fil
CoOt (
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality 2013