412908_Well Construction - GW1_20130422

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
▪ 1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit R:
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)
❑ Industrial/Commercial
❑ Irrigation
OMunicipal/Public
OResidential Water Supply (single)
o Residential Water Supply (shared)
Non -Water Supply Well:
OMonitoring °Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
o Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
0 Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 03/2 rJ/13 Well IDS
5a. Well Location:
Paula Smith
Facility/Owner Name Facility IDM (if applicable)
210 Sand Dollar Ln., Hampstead, NC 28443
Physical Address, City, and Zip
Pender
County Parcel IdentilicationNo.(PIN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
6. Is (are) the well(s): L7Permanent or DTemporary
7. Is this a repair to an existing well: DYes or ECNo
If this is a repair, fill out Imown well construction information and explain the nature of the
repair under N21 remark section or an 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: 100
For multiple wells list all depths if different (example- 3@200' and 2@100')
(H)
10. Static water level below top of casing: 1 1 (ft)
If water 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:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3q([.10%
'e
-
For Internal Use ONLY: \ 1�1 1 1 • I. 1 4.0 kJ14.
WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft
ft
15. OUTER CASING (for
multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
1.5 ft'
80 ft
4 In.
PVC
16..INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
fL
in.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
fL
in.
ft
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 It
24 it
Grout
Poured
ft
fL
ft
ft
19.SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
fL
ft
ft
ft
20. DRILLING
LOG (attach
additional sheets If nece sary)
FROM
TO
DESCRIPTION (color, has near, soil/rock type, grain sire, etc.)
0
26 ft
Sandy clay
26 ft
72 ft
Clay
72 It
100 ft
Limestone
ft.
ft.
ft.
fL
ft
fL
{� @ p? �
APR 6?011
ft
ft
L
21. REMARKSVVATEf{QO�,LIj�'aEttl4
INFORMATION PROn qq mi InUlLNIT
22. Certification:
03/25/13
Signs use of Certified Well C.C• OvDate
By signing this form, I hereby centff that the well(s) was (were) constructed in accordance
with I SA NCAC 02C .0100 or 1 SA NCAC 02C .0200 Well Construcion 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 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:
Dildsion of Water Quality, Undergs!qugd Injection Control Programs,
1636 Mall Service Center, ale' 7 9 1
24c. For Water Supply & Infection W ei)s ifin addition to sending the fonds to
the address(es) above, also submit one eo,°ppy of this form within 30 d4psof
completion of well constmotion to the cobOl-health-departmentacounty
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Ian. 2013