412459_Well Construction - GW1_20130408

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531
NC Well Contractor Certification Number
Applied Resource Management, PC
Company Name
2. Well Construction Permit #: NA
List all applicable uell consnuctionperwrits (Le. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Comm ercial
O bligation
°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 Teohnology
❑Geothermal (Closed Loop)
o Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑ Salinity Barrier
°Stormwater Drainage
°Subsidence Control
o Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/1 1 /13
5a. Well Location:
Hampstead Town Center
Well ID,*MW-3
Facility/Owner Name Facility ID# (if applicable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and Zip
Pender
3293-86-8315-0000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decinsal degrees:
(if well field one latt/long is sufficient)
24 deg. 23' 23.54" N 77 deg. 40' 34.63"
6. Is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or ENo
Unlit is a repair, fill out latown well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. Number of wells constructed: 4
For multiple infection or non -water supply wells ONLY with the same conshndion, you can
submit one form.
9. Total well depth below land surface: 16.5 (ft)
For multiple wel6 list all depths ifdifferent (example- 3®200' and 2@100')
10. Static water level below top of casing: 6.39
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
12. Well construction method: Auger
(i.e. auger, rotary, cable, direct push, etc.)
(ft)
For Internal Use ONLY: 412 4 5 e
5
14. WATER ZONES
FROM
TO
DESCRIPTION
5 rt
16.5
Suriicial
ft.
ft
15. OUTER CASING (for multt.eased wells) OR LINER (if ap. Nesbit)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+3 rt.
1.5 rt
2 i"•
SCH-40
PVC
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
tt
ft.
in.
ft
ft
in,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
1.5 ft
16.5 ft
2 '"'
0.010
SCH-40
PVC
tt
ft.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 rt
1 D•
Bentonite
Poured
ft.
ft.
ft
ft
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1 f6
16.5 ft
Coarse Sand
Poured
ft
ft
20. DRILLING
LOG (atta
h additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
ft
ft.
See attahced.
ft
ft
it.
it.
ft.
ft
ft
ft
MAR y h LUI1
rt
ft
tNk;6GGQUALITYCCCTICN
INFORMATION PROCESSING UNIT
Ft
ft
21. REMARKS
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
22. Certification:
Signature of Certif} dWell Contractor
2
Date
By signing this from, I hereby certify that the well(s) uns (were) constructed in accordance
with 15,4 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 additional pages if necessary.
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SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit thi
construction to the following:
Division of Water Qua / Information Processing
1617 Mall Service Caterr le+ CZ2too
246. For Iniection 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 web
construction to the following:
of well
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suooly & Iniection 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,
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