414562_Well Construction - GW1_20130708

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
5 6 2
I. Well Contractor Information:
Harry Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit *I: N/A
List all applicable well construction permits Be. Counhz State, Variance, etc.)
3. Well Use (check well use):
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for mold -cased wills) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS 1 MATERIAL
1.5 ft 87 ft 4"
in.
PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
in.
17. SCREEN
Water Supply Well:
°Agricultural
❑Geothemmal (Heating/Cooling Supply)
IIndustrial/Commercial
Dlrrigation
°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)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed; 05/23/2013�Vell m# N/A
--5a'. Well Location:
Yuting Rui
N/A
Facility/Owner Name Facility ID# (if applicable)
809 Grandview Drive, Hampstead, NC 28443
Physical Address, City, and Zip
Pender •
3293-60-2331-0000
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 22 31.93 N 77 41 13.73
6. Is (are) the well(s): ©Permanent or °Temporary
w
7. Is this a repair to an existing well: °Yes or DNo
if this is a repair fill out known well construction information and explain the nature of the
repair corder r21 remarks section or on the hack of this form.
8. Number of wells constructed: 1
For mullip/e Injection or non -water .supply wells OAZI' with the same ctnrstructiaa, you can
submit one form.
9. Total well depth below land surface: 87 (ft.)
For multiple wells list all depths ifdifferenl (example- 3ae00' and 2@100')
10. Static water level below top of casing: 11
If water level is above casing, use "-"
IL_Bhol oreeaianteter: 4 (an.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
(ft)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 100+ Method of test: Airlift
13b. Disinfection type: HTH Amount: 1 Pound
FROM
R.
TO
ft
DLMIEIER
m.
SLOT SIZE
TIDCETTSS
MATFBLJ
ft.
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENTMETHOD & AMOUNT
0
ft.
20 R:
Bentonite
Poured
ft.
ft
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessay)
FROM
0
ft.
TO
10 ]t
DESCRIPTION (color; hardness, soil/rock type, gran the, etc)
Tan brown find sand
10 ft.
20 ft.
Reddish brown clay
20 ft
40 ft,
40 It
87 ft.
_-_—Gray-claywithshell
Softto very hard limestone rock
ft.
ft.
ft.
ft.
ft
21. REMARKS
ft
JUL 6
n
- '..13
INFfRi ATIQN PROCESSIN
22. Certification: -
Sfgnanve ofCer(ifiyd Well Contractor
6zr'3
Date
By signing this form, I hereby certify 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 All Wells: Submit this form within 30;'days gfg&o llo tprf yell
construction to the following: �1,. (ttfIJ
Division of Water Quality, Informatiin t rocessing Unit,
1617 Mail Service Center, Raleigh, IS27699r16L ------
�4b _For Injection Wells- in addition in send inglhr fo,nlln the address in',4a
above; also submit a copy -of PUS Toim aithiii 3Q days ofcrtlpletion orS3eI1 -
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department ofEnv iroumenr and Natural Resources- Division of Water Quality Revised Jan. 2013