415168_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
Donald H. Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Nam e
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
DGeothermal (Heating/Cooling Supply)
❑Industrial/Commercial
D Irrigation
DMunicipaliPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
OGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
D Groundwat er Rem ediati on
❑Salinity Barrier
D Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 7/24/2013Well ID# N/A
5a. Well Location:
Michael & Susan Kiel
N/A
Facility/Owner Name Facility ID# (if applicable)
3874 Hearndon Lane, South Port, NC 28461
Physical Address, City, and Zip
• Brunswick County
207714420809
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33 56.801 N 78 5.772
6. Is (are) the well(s): ©Permanent or DTemporaiy
7. Is this a repair to an existing well: DYes or 1 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: 3
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: 250 (ft)
For multiple wells list all depths if different (example- 3@.200' and 2@100')
10. Static water level below top of casing: 7 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 5 7/$
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct pushetc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
.1.
568
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft
ft.
ft.
15. OUTER CASING (for multi -cased welts) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
+/-250 ft.
3/4 in.
HDPE
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
_
MATERIAL
ft
ft.
in.
•
ft
ft.
in.
17. SCREE_ N
FROM
TO
DIAAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft
ft.
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.
55 ft.
Sandy clay/clay
55 ft.
95 ft.
Limestone (sandy)
95 ft.
125 ft.
Sandy limestone sandstone mix
125 ft.
200 ft
Alternating sandy limestone and
ft.
ft
mud rock
200 ft.
260 ft-
Stiff clay
ft.
ft.
21. REMARKS A i 1► , s` J 'pi ��
a' r i' �1 {y, [k �j•y�"`p6` ``� trip` e��p��pxt qp p �5'60
It F, �� N•{-t-E"C g. td-j• �i lei C t1' i :, / B1,
22. Certification:
Signature of Certified Well Contractor
7f U '.� iaii"�i 9k?c iV `A fib`.. ':*g .?�M�Uy•
Date
By signing this form, 1 hereby certfi' 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
cop), 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 t^, pr vide additional well sii,t dgtpj s or well
construction details. You may also attt aes, � ee 'a ' ibna� �:;fGes�_
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this
construction to the following:
wf i 0 ia4 2Qletrjof well
v
Division of Water Quality i formation Prone slt1g Unit;
1617 Mail Service Center, Raleigh NC 27699-1617
246. 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 111aiI 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.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013