413922_Well Construction - GW1_20130510

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Donald Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management
Company Name
2. Well Construction Permit #: WP0290801
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑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 Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 04/05/1
5a. Well Location:
Mike Bradstreet
Facility/Owner Name
3234 Marathon Ave.
WellID#
Facility ID# (if applicable)
Physical Address, City, and Zip
New Hanover
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑ Yes or E No
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 this form.
8. Number of wells constructed:
For nzultiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Totlal well depth below land surface: 120 (ft.)
For multiple wells list all depths if different (example- 3 c@i 200' and 2@100')
10. Static water level below top of casing: 12 (fl.)
If water level is above casing, use "+ "
11. Borehole diameter: 4 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Low Method of test: Airlift
13b. Disinfection type: HTH Amount: 3g c` 10%
'For Internal Use ONLY:
4i32
1�t, S3ATER ZONES
FROM
ft.
TO
ft.
DESCRIPTION
ft.
ft.
FROM
TO
INGG (foeinutti cased wells) QR LMR (if ap01161 )
DIAMETER
THICKNESS
MATERIAL
0
ft.
40
ft.
6
in.
PVC
NNE EA`SIl`tC OR'' TUBING (g+eothexnnai closed IQ
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft.
100 f'
4
in.
PVC
ft.
ft.
in.
REE
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
100 ft'
120 ft.
4
in.
.20
PVC
ft.
ft.
in.
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
25
ft.
Grout
Pumped
50
ft.
55 rt.
Bentonite
Pumped
ft.
ft.
SAND
"applicable;
FROM
TO
MATERIAL
EMPLACEMENT METHOD
55
ft.
120 ft.
Sand
Poured
It.
fit.
f DRIL-LIN EOI (attach a idit %
1f, hi
70"
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0
ft.
20
ft.
Sandy clay
20
ft.
40
ft.
Clay w/ shell hash
40
ft.
55
ft.
Limestone (sandy)
55
ft.
70
ft.
Sands w/ some clay
70
ft.
120 ttt.
Sands
ft.
ft.
MAY - 3 2013
ft.
ft.
(109,1
a 2.t T QUA2 . _ r
e�'POCE i`� , I.,�t. T
4/12/13 Pulled well back to where screen is bU . evelo /
p
water flow to 30 gpm
22. Certification:
04/05/13
Signature of Certified r e Co'-w. tor Date
By signing this form, I hereby 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
construction details. You may alp a ach ackaif hat ' n ary.
ki
SUBMITTAL INSTUCTION
24a. For All Wells: Submit
construction to the following:
a�
af
0
letion of well
Division of Water Qu Informat roc ssing-Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. 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 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 & Infection 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.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Revised Jan. 2013