413324_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #: W 13-014 H
List all applicable well construction permits 0.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
OGeothennal (Heating/Cooling Supply)
❑ lndustrial/Commercial
Olrrigation
OMunicipal/Public
®Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
OGeothennal (Closed Loop)
❑Geothennal (Heating/Cooling Retum)
❑Groundwater Remediation
DSalinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 04/09/1
5a. Well Location:
Riptide Builders
Facility/Owner Name
193 S. Kingfisher Ln. ( lot # 13 Tidewater Landing)
Physical Address, City, and Zip
Pender
3 Well ID#
Facility ID# (if applicable)
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is (am) the well(s): ©Peru anent or ❑Temporary
7. Is this a repair to an existing well: ❑ Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair wider #21 remarks section or on the back of this 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: 105 (R.)
For multiple wells list all depths if different (example- 3 rd'00' and 2 r@100')
10. Static water level below top of casing: 20 (ft.)
Irwater level is above casing, use "+••
11. Borehole diameter: 4 (in)
12. Well construction method: Rotary
(i.e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3q( 10%
For Internal Use ONLY:
A 133,..
14. WATER ZONES -
FROM
TO
DESCRIPTION
n
n
ft.
ft
15. OUTER CASING (for multi:ased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
+1.5 n
85 n
4 in.
PVC
16 INNER
CASING OR TUBING (geothermallclosed-ioop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
n
iL
in.
n
it
in.
17. SCREEN "
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
It.
ft.
in.
n
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD @ AMOUNT
0 it
25 n
Grout
Pumped
n
n
n
n
19. SAND/GRAVEL
PACK
(if applicable) ...
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
n
n
ft.
20. DRILLING
LOG (attach
additional sheets If necessary)
FROM
TO
DESCRIPTION (color, bardnes; solVrock type, grain size, etc.)
0 It
78 n
Sandy clays
78 n
105 n
Limestone
0.
n
n
n
n
n
MAY -3zu13
n
SECTION
ftWATER
QUALITY
INFORMATION PROCESSING UNIT'
21: REMARKS
22. Certification:
Signature of Certified Well Contract°
04/09/13
Date
By signing this form, I hereby certrfv dm ta well(s) was (were) constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C .0200 Well Cons auction 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 aVta,
i{ atd'i-;nl ti s fifnecessary.
SUBMITTAL
ary.
SUBhITTAL INSTUCTIONS
24a. For All Wells: Submit th s onnielyn t0 fl co :l' I-tion of well
construction to the following: i F t1
Division of Water Qu Information Processing nf
1617 Mail Service CenteF•-I&11ergly NC2T6991811
24b. For Injection Wells: In addition to sending the fonn to the address in 24a
above, also submit a copy of this fonn within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Senice Center, Raleigh, NC 27699-1636
24c. For Water Sumni, & 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 department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources —Division of Water Quality Revised Jan. 2013