413325_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Infotnnatiom
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit 11: W 13-015 H
List all applicable well construction permits a e. Cowry, State, Variance, etc.)
3. Well Use (check well use):
FROM
For Internal Use ONLY:
413325
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
15. OUTER CASING (for multi -cased wells)OR LINER (if applicable)
TRICICCESS l MATERIAL
PVC
+1.5 rt
85
n
4
in.
16. INNER:CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
in.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lnduslriaVCoutmercial
❑Irrigation
OMunicipal/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 Retum)
°Groundwater Remediation
❑Salinity Barrier
fStomwater Drainage
°Subsidence Control
°Tracer
°Other (explain under 1121 Remarks)
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
in.
ft.
in,
18. GROUT'.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
25
n
Grout
Pumped
n
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0
ill
TO
78 ft.
DESCRIPTION (color, hardness, solIrock type, grain sire, etc.)
Sandy clays
4. Date Well(s) Completed: 04/08/13
5a. Well Location:
Riptide Builders
Well Mil
Facility/Owner Name Facility IDh (if applicable)
177 S. Kingfisher Ln. ( lot # 14 Tidewater Landing)
Physical Address, City, and Zip
Pender
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat/long is sufficient)
N W
6. Is (are) the mills): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑ Yes or DNo
If this is a repair, fall out Know well conststcdon it fonnatiorr and explain the nature of the
repair under #21 remelt section or on the back afthis form.
8. Number of wells constructed: 1
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:
For multiple wells list all depths if different (example- 3@200' and 2 r@100')
10. Static water level below top of casing: 20
If water level is above casing, use ••+••
11. Borehole diameter: 4 (fin.)
Rotary
105
12. Well construction method:
(ft)
(n.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3CI 10%
78
105 a
Limestone
ft
ft.
a
ft.
R.
11.
ft.
MAY - 3 2013
21.:REtyrARxs .. WATER OUALIIY-SE(.IION
INFORMATION PROCE95INl3 UNi7
22. Certification:
04/08/13
Signature of Certified Well Contractor I \ Dtruate
By signing this form, I hereby certify that the 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
constmction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this
construction to the following:
MAY 13 2013
Division of Water Quaff •$nfonnation Processing LI ?t l
1617 Mail Service Centel Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the Conn to the address in 24a
above, also submit a copy of this fonn within, 30 days of completion of well
constmcton to the following:
of well
EC FIVE
within 30 days of comp
i.
Division of Water Quality, Underground Injection Control Program,
1636 Mail Senice Center, Raleigh, NC 27699-1636
24c. For Water Supplv & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
completion of well construction to the county health departnent of the county
there constructed.
DIAMETER
TO
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Jan. 2013