412363_Well Construction - GW1_20130318

WELL CONST ' UCTION REC
For Internal Use ONLY:
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 #: ®N0662640
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
DGeothermal (Heating/Cooling Supply)
['Industrial/Commercial
Dlrrigation
DMunicipal/Public
DResidential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
DMonitoring ❑ Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
D Stormwater Drainage
D Subsidence Control
D Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 02/06/13 Well ID#
5a. Well Location:
Thomas Foster
Facility/Owner Name
8802 Nadie Ln.
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)
N W
6. Is (are) the well(s): ©Permanent or DTemporary
7. is this a repair to an existing well: DYes or ENo
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: 1
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: 180 (ft.)
For multiple wells list all depths if di, fjerent (example- 3@200' and 2@100')
10. Static water level below top of casing: 6 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4
12. Well construction .method: Rotary
(i.e.-auger, rotary, cable, direct push; etc.)
4 i J 6 3
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
.(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
+1.5 ft
180 ft.
4 in.
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
20 ft.
Grout
Pumped
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable) -
_
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
22 ft.
Sandy clay (cave @ 18')
22 ft
105 ft.
Limestone
105 ft.
140 ft.
Clay / mud rock
140 ft.
180 ft.
Sandstone
ft.
ft..
ft.
ft
ft.
ft.
21. REMARKS
MAR 1 4 20!
j
FOR WAITER SUPPLY WELLS ONLY:
13a. Yield (gpm) 80 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3g @ 10%
Form GW-1
22. Certification:
Signature of Certified Well Contr
WATER QUALITY SECTION
NFORMATION PROCESSING UNIT
02 06/ 1
Date
By signing this form, 1 hereby cent '. t the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NC ' ' 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 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 Infection 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
FrtppePTn ti+'X'ih..
24c. For Water Supply & Infection; a ls:� dditfon to'se iding,the Corm to
the address(es) above, also submiOWTOpyOf this form within 30 days of
completion of well construction to 'Vie co 4,ealth t of tie county
where constructed. }`
North Carolina Department of Environment and Natural Resources - Division of Water Qiiilily
Revised Jan. 2013