412457_Well Construction - GW1_20130408

WELL CONSTRUCTION RECORD
This form can be used for single or multiple walls
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531
NC Well Contractor CertifcationNumber
Applied Resource Management, PC
Company Name
2. Well Construction Permit #: NA
List all applicable ,ell construction permits (i.e. Comity, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
°Agrioultural
DGeothernal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
oMunicipal/Publio
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
MMonitoring oRecovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Rem ediati on
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/11/13 Well ID# M W-1
5a. Well Location:
Hampstead Town Center
Facility/Owner Name Facility ID# (if applieable)
17270 Highway 17 N, Hampstead NC 28443
Physical Address, City, and Zip
Pender
3293-86-8315-0000
County Parcel IdentificationNo. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
24 deg. 23' 30.56" N 77 deg. 40' 35.12"
W
6. Is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or MNo
If this is a repair, fill out Fawn well construction information and explain the nature of the
repair under #21 remelt section or on the back of this form.
8. Number of wells constructed: 4
For multiple injection or non -eater supply wells ONLY with the same consouction, you can
submit one form.
9. Total well depth below land surface: 17
For nnddple wells list all depths if different (example- 3©200' and 2Qa 100')
(ft)
10. Static water level below top of casing: 7'48 (ft)
If water level is above casing, use "+"
11. Borehole diameter: 8
12. Well construction method: Auger
(ie. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:Et
'1 L'PV
1
14. WATER ZONES
FROM
TO
DESCRIPTION
7 ft
17 ft
Surficial
ft
ft
15. OUTER CASING (for multi -cased wells) OR LINER (B applicable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
+3 ft
2 tr.
2 in.
SCH-40 PVC
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
in.
ft
ft.
in
17. SCREEN ..
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 ft
17 ft
2 in'
0.010
SCH-40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 it
1 rt
Bentonite
Poured
rt
ft.
ft
f4
19.SAND/GRAVEL
PACK
Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1
17 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
f6
ft
ft
ft.
FL
ft
ft
ft
MAR
2 5 ?OH
ft
ft
21. RRMARKC titiht lER ®UFikl) Y `,s'bnC1lCN
!(dFURrvu l IUN PFt0CSSSINGs UNIT
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
Signature ofce fled Well Contractor Date
By signing this form, I hereby coil)" that the walks) was (were) constructed in accordance
with 15,4 NCAC 02C .0100 or ISA 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 wQIk I§§YYQ 44--^ {{'o'®®,,� &pp'"�`� -r
You may use the back of this pa �C 'Jd�0,1ad foi al'40'elle''site }ails or well
construction details. You may alstj}a eh additional pages if accessi
SUBMITTAL INSTUCTIONS APR 0 8 2013
24a. For All Wells: Submit thill , rm within 30 days of camon of well
construction to the following: B�/•�,,,�..,..�..�..----'--
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
246. Eor Infection Wells: In addition to sending the form to the address in 24a
above, also submit a Dopy of this form within 30 days of completion of well
construction t6 the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Stonily & Injection Wells: Ip 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 of Environment and Natural Resources — Division of Water Ouality
Revised San 7011