413439_Well Construction - GW1_20130513

WELL CONSTRUCTION RECORD
This form can be used for sin.le or multiple wens
1. Well Contractor Information:
For Internal Use ONLY:
41 3139
George R. Bridger
Well Contractor Name
2393A
NC Well Contrsetor Certification Number
Bridger Drilling Ent., inc.,dba Carolina Drilling
Company Name
2. Well Construction Permit At;
List all applicable -well construction permits (Le. COUtity, State, Variance, etc.)
3. Well Use (check well use);
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
0 Industrial/Commercial
°Irrigation
Non -Water Supply Well;
ElMonitoring
Injection Well:
°Aquila- Recharge
°Aquifer Storage and Recovery
°Aquifer Test
0 Experimental Technology
0Geothennal (Closed Loop)
0Geothermal (Heating/Cooling Return)
0 rvhin icipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
°Recovery
E3Groundwater Remediation
°Salinity Bonier
0 Stommater Drainage
0 Subsidenec: Control
°Tracer
°Other •(explain under #21 Remarks)
4. Date Well(s) Completed: April 2, 2013
5. Well Location:
Coastal Cleaners
DSCA#65-0004
Facility/Owner Name Facility ID# (if applicable)
604 Shipyard Blvd, Wilmington, NC 28401
Physical Address, City, and. Zip
New Hanover
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or dechnal degrees:
()f well field, one lat/long is sufftcient)
34 11' 26.90" N 77 563.10"
6. Is (are) the wells); LOPermanent or °Temporary
7. Is this a repair to an existing [Wes or ON°
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of/his form,.
8. Number of wells'constructed:
Formultiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below laud surface: 25
For nmItiple wells list all depths f different (example- 3,@,200" and 2@100)
(ft.)
10, Static water level below top of easing: 18.6 (ft.)
limier level is above casing, WO "+"
11. Borehole diameter: 1 0
12. Well construction method: Auger
(Le. auger, roam cable, direct push, etc.)
(h.)
13. FOR WATER SUPPLY WELLS ONLY;
13a. Yield (gpm) Method of test:
13b. Disinfection type:
Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft,
ft.
ft.
15, OUTERCASING (for multi -cased wells)0R-LINER.(if vplicable)
FROM TO DIAMETER 1, THICKNESS MATERIAL
0 ft. ,i5 a 2 in- '; sch 40 pvc
16, INNER CASING OR -TUBING (geothermal dosed4o9)
FROM TO DIAMETER I THICKNESS MATERIAL
ft.
ft.
tn.
ft.
ft
17; SCREEN
IS, GIW
FROM
ft.
TO
11
ft.
ft.
DIAMETER
2
in.
In.
MATERIAL
ft. neat
SLOT SIZE
010
THICKNESS
sch40
MATERIAL
pvc
EMPLACEMENT METHOD & AMOUNT
in -place
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft- ,
25
ft.
sand
tremie
ft.
ft.
20, DRILLING LOG (attach additional sheets if necessary)
FROM TO j DESCRIPTION (color, hardness, soil/rock type, grain size, ete.)
0 ft• 25
ft.
ft,
ft.
ft.
ft.
ft.
Tan and Gray sand
ft.
MAY
REMARKS
22. Certification:
'/:gn4ing
Si of Certified Well Co actor Date
this form, 1 here 7 certify that the well(s) was (were) constructed in accordance
with 15A 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
constnietion details. You may also attach additional pages if necessaty,
ft.
WATER QUALITY SECTU:yv
iNTOKIABON PROCESV, ‘)11
41.v, ralar.
13
24. Submittal Instructions:
April 30, 2013
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 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 Supplv & Geothermal 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_
Forte GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised Jan, 2013