415169_Well Construction - GW1_20130812

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. W't'ell Contractor Information:
Donald H. Cummings
Well Contractor Name
2412-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: NIA
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
D Agricultural
©Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
D Irrigation
❑Municipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
D Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothenmal (Heating/Cooling Return)
❑ Groundwater Rem ediation
DSalinity Barrier
D Stonnwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under 421 Remarks)
4. Date Well(s) Completed: 7/22/2013`Vell ID# N/A
5a. Well Location:
Darko Residence
N/A
Facility/Owner Name Facility ID# (if applicable)
2781 Pinecrest Drive, Southport, NC 28461
Physical Address, City, and Zip
Brunswick County
206610354135
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 55.557
N 78 7.898
6. Is (are) the well(s): DPermanent or ❑Temporary
7. Is this a repair to an existing well: DYes or ONo
If this is a repair, fill out /mo>tn 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 -stater supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 125 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@I00')
10. Static water level below top of casing: 7 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 5 7/8
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push_ etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpin) 8 0 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3%(C710
For Intemal Use ONLY:
415169
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
+1.5 ft.
100 ft
4 in.
Sch40
PVC
16. INNER
CASING OR TUBLNG
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
ft
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
100 ft.
120 ft
4 in.
.020
Sch40
PVC
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
24 ft.
Grout
Poured
90 ft.
95 ft
Bentonite
Tremmie
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
95 ft.
120 ft
Coarse
Poured
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
33 ft.
Sandy clay/clay
33 ft.
125 ft
Sandy Limestone
125 ft.
ft.
Clay
ft.
ft.
ft
ft.
ft.
ft
ft.
ft.
21. REMARKS . fi i �. `'l`. '1 i i l
, t a
; f � L�ZC�-i:� 1� E S. i Y .'ij �. 1 �< Y
•1144y� .'1 . 4 r ^ �' N. �LO YT E0 (, (l `[:gig
22. Certification:
Signature of Certified Well Contractor
R'�FDif'®`et@F�r�5°8f���.Tt�brl�a+'rrf�'�i'S b`
urtkr14.0
Date
By signing this form, 1 hereby certifi' that the well(s) was (were) constructed in accordance
with 15A NC4C 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 prop e,_additi nal w .11 i d x i is r, ell
construction details. You may also attach ad It oiya1 a seces ,
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form
construction to the following: C`A
AUGI tin 30 days of comp et on o
Division of Water Quality, Info at'ron Processing 'Uiii ,
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:
ell
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supple & 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