414387_Well Construction - GW1_20130728

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Jeffrey A Stewart
Well Contractor Name
(NCWC) 2540-A
NC Well Contractor Certification Number
Mid -Atlantic Drilling, Inc.
Company Name
2. Well Construction Permit #:
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)
DlndustriaUCommercial
Dlrrigation
DMunicipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
ZiMonitoring
DRecovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
DExperimental Technology
DGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
DGroundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
DSubsidence Control
DTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 6/26/13
5a. Well Location:
Lockwood Folly Golf Course
Well ID# MW-2
Facility/Owner Name Facility ID# (if applicable)
19 Clubhouse Drive Holden Beach NC 28462
Physical Address, City, and Zip
Brunswick
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 54.07 N 78 13 28.44
6. Is (are) the well(s): ©Permanent or DTemporary
7. Is this a repair to an existing well: DYes or ZINo
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 multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 3 a@ 17 (ft.)
For multiple wells list all depths f different (example- 3 a 200' and 2@a 100')
10. Static water level below top of casing: 8.34 (ft.)
If water level is above casing, use "+ "
1. Borehole diameter: (in.)
12. Well construction method: auger (4 114)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
i= r:) t„,
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft,
15. OUTER CASING1for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
2 in.
sch 40
pvc
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER j
THICKNESS
MATERIAAL
ft.
ft,
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER .
SLOT SIZE
THICKNESS
MATERIAL
10 ft.
17 ft.
2 in.
0.01
sch 40
PVC
ft.
ft.
--
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
1 ft.
3 ft•
bentonite
pour
0 ft.
1 ft*
concrete
pour .
ft.
ft.
19. SAND/GRAVEL PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3 ft.
17 ft.
torpedo
pour
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, rain size, etc.)
0 ft.
17 ft.
Orange and tan fine- and medium -grained
ft.
ft.
quartz sand
ft.
ft.
ft.
ft.
ft.
ft.
•t (E . ,
i
ft.
ft.
.
21. REMARKS A g R ,ti.UAEf Kati,; T t�., .
s'\s i- Q:' MP i ii.. i tt`• R O CES S i G i: N ; i
22. rti cation:
l)
Sfg e reertifipd 'ellContractor
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.
7/15/2013
Date
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 cope of this form wi ,3 daykra et df" i
construction to the following:� t(��Rl 7
Division of Water Quality, Undergrou ` njecti n Contrel Peq am,
1636 Mail Service Center, Ra `: h, N 49%4636
24c. For Water Supply & In'ection Wells:
the address(es) above, also submit one copy
completion of well construction to the county
where constructed.
ddition to sending the form to6
/this form vy in.,3 .dayys-Gf-
eaffdepartment of the county
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Revised Tan. 2013