410469_Well Construction - GW1_20130211

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412A
1. WELL CONTRACTOR:
Donald H. Cumminas
Well Contractor (Individual) Name
Applied Resource Manaaement. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
( 910) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# H-0271
OTHER ASSOCIATED PERMIT#(i( applicable)
SITE WELL ID/Rif applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply It
DATE DRILLED 1 1 /20/12
TIME COMPLETED 1 :00 AM ❑ PM D{
4. WELL LOCATION:
CITY: Hampstead
Tract 9 Holly Hill Rd.
COUNTY Pender
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley I 'Fiat ❑Ridge ❑Other
LATITUDE 34 ° 25
LONGITUDE 77 ^ 35
52.2500 " DMS OR
40.9000 " DMS OR
DD
DD
Latitude/longitude source: I 3PS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
John Sickle
Owner Name
35 Coleman Circle
Street Address
Hampstead NC 28443
City or Town State Zip Code
(910 ) 540-8933
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 100'
b. DOES WELL REPLACE EXISTING WELL? YES lir NO ❑
c. WATER LEVEL Below Top of Casing: 8' FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1 .5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 80+ METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3a G( 10%
9.
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
WATER ZONES (depth):
7. CASING:
Top +1.5
Top
Top
Thickness/
Depth Diameter Weight Material
Bottom 80' Ft.4" SCH40 PVC
Bottom Ft.
Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 24' Ft. Bentonite Tremmie
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0' / 11'
11' /42'
42' /60'
60' / 100'
12. REMARKS:
Sand
Formation Description
Sandy clay / clay
Rock clay mix
Limestone
p ri r ;ipr; V rneest=:n
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN _.
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD; HAS BEEN -
PROVIDED TO THE WELL OWNER. ...._..' i""
SIGNAT RE OF CERTIFIED WELL C RACT
10521P
DATE
Donald H. Cummings
PRINTED NAME OF PERSON CONSTRUCTI
NG THE WELL
Submit within 30 days of completion to: Division of Water Qualify - information Processing,
1617 Mail Service Center, Raleigh; iWWC 27699-161, Phone : (919) $07-6300
Form GW-1a
Rev. 2/09