414217_Well Construction - GW1_20130617

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
60
1. Well Contractor Information:
Harms Michael Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, PC
Company Name
2. WeIl Construction Permit IV: Wl'0009674
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
DAgri cultural
DGeothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
❑Irrigation
Non -Water Supply Well:
D Monitoring
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
DGeothermal (Closed Loop)
DGeotherrnal (Heating/Cooling Return)
DGroundwater Remediation
❑Salinity Barrier
DStormwater Drainage
DSubsidence Control
DTracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 5/21/13
5a. Well Location:
Keith McCahan
Facility/Owner Name
321 Windsong Road
Well ID# Potable Well
Facility ID# (if applicable)
Physical Address, City, and Zip
Wilmington, NC 28411 R0361901532000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 16 48.33 N 77 48 15.86
W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or IENo
If this is a repair, fill out known well construction information and explain the nature of the
repair under i=21 remarks section or on the back of this form.
8. Number of welts constructed:
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: 195 (ft)
For multiple wells list all depths if different (example- 30200' and 2(a?100')
10. Static water level below top of casing: 21 (ft.)
If water level is above casing. use "pp= "
11.Borehole _diameter: _ 5-7/0 to -7/8
12. Well construction method: Rotary
(i.e. auger, rotary; cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
>1 00
13a. Yield (gpm) Method of test: Air-lift
Granular Chlorine
13b. Disinfection type: Amount: 1 l b .
Form GW-1
14. WATER ZONES
- FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DLAMETER
THICKNESS
MATERIAL
0 ft.
60 ft.
6 ill'
SCH40
PVC
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DLAMETER
THICKNESS
MATERIAL
0 ft
165 ft.
4 in.
SCH40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERLAL
165 ft
195 ft-
2 in'
0.010
SCH40
PVC
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
25 ft
Bentonite Chik
Poured
ft.
ft
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
155 ft.
195 ft
#2
Poured
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft-
8 ft.
Tan fine sand
8 ft
25 ft.
Gray clay
25 ft
45 ft.
Tan M-F sand (some coarse)
45 ft•
80=�_--fr•--
_---- - - Soft to hard limestone rock
80 ft•
155 ft•
PeeDee sands and clays
155 ft
195 ft
Soft to med. hard sandstone
ft.
ft.
21. REMARKS
JLM1 2 V tK,i 7O3
22. Cer i fication:
INFORMATION PROCESSING UN
IT
S _ attire of. Certified 'ell Contractor
7_/3
ate
By signing this foiI11, I hereby certf that the well(s) was (were) constructed in accordance
with 1 5A NCAC 02C . 0100 or 1 5A 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 attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this ,-4.4 within 30 days of completinof well
u1 7 2013
Division of Water Qualitformation Processing Unit,
construction to the following:
*4
1617 Mail Service Cen
aleigh, NC 27699-1617
24b. For Injection 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:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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.
North Carolina Deparunent of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013