410240_Well Construction - GW1_20130114

NONRESIDENTI RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wate r Quality
WELL CONTRACTOR CERTIFICATION # 2412A
1. WELL CONTRACTOR:
Donald H. Cummin s
Well Contractor (Individual) Name
Applied Resource Management P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Ham • stead
City or Town
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
NC
State
28443
Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery ❑ Injection 0
Irrigation' Other 0 (list use)
DATE DRILLED 1 1/30/12
4. WELL LOCATION:
513 Moss Tree Dr.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Wilmington COUNTY New Han
.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
D Slope ❑ ValleyWrFlat ❑Ridge ❑Other
LATITUDE 34 ° 14 , 30.6400 DMS OR DD
LONGITUDE 77 ° 48 ' 55.4300 DMS OR
--- DD
Latitude/longitude source:
(location of well must be BPS �°p°graphic •map
shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name
Street Address
Facility ID# (if applicable)
City or Town
Logan Homes
Contact Name
60 Greaary Rd_ Spite 1
Mailing Address
BeIville
City or Town
( 9.10 )67-1 348
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_lag______
9d'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO a%
c. WATER LEVEL Below Top of Casing:
(Use "+" if Above Top of Casing) FT.
State Zip Code
_NC 28451
State Zip Code
•
•
•
Top
: Top Bottom Ft.
: Top 160'
Top
Al n
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.
METHOD OF TEST Airlift
e. YIELD (gpm): 80
f. DISINFECTION: Type HTH Amount 3gA10%
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 1.5'+ Bottom 160' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0' Bottom 24' Ft. Grout Poured
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Bottom 190' Ft.010 in. 2" in. PVC
Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top Bottom Ft.
Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0' / 45' Sandy clay / clay
45' / 110'
Limestone (void at 50')
110' / 150' Mud rock / clay
150' / 190' Sandstone
12. REMARKS:
RECEIVE
JAN Z 3
1lormadan Processing unit
.1 •
l DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
• ' D HAS B N P - OVIDFD TO T, E WELL OWNER.
SI ATURE OF CERTIFIED WELL . ! T 11 T 2
�,. OR DATE
: Donald H. Cummings -.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division
'IE�1? Mail Service Center, Raleigh, NCof Water Quality - Information Processing,
9 �27699-161, Phone : [phone]