412449_Well Construction - GW1_20130325

WELL C NST UCTFI N RECO
This form can be used for single or multiple wells
1. Well Contractor Information:
H. Michael Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management
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)
D Industrial/Commercial
❑Irrigation
DMunicipal/Public
DResidential Water Supply (single)
:Residential Water Supply (shared)
Non -Water Supply Well:
DMonitoring
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
DExperimental Technology
DGeothermal (Closed Loop)
DGeothermal (Heating/Cooling Return)
❑Groundwater Rem ediation
D Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
DTracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 03/06/13 Well ID#
5a. Well Location:
Steven Anderman
Facility/Owner Name
2599 Hillsborough Dr.
Facility ID# (if applicable)
Physical Address, City, and Zip
Brunswick
219J D024
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
33'56.560 N 78'08.441
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. is this a repair to an existing well: D Yes or CJffo
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: 5@255'
For multiple wells list all depths if different (example- 3@200' and 2 c@100')
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LIFTER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop) .
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
250 ft.
1 in.
H D P E Loops
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICIONESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
255 ft
Thermex .
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.
45 ft.
Fine to med brown to tan sand
45 ft
55 ft.
Coarse to med gray sand
55 ft
60 ft.
Gray clay
60 ft.
120 ft.
Limestone rock
120 ft
260 ft.
Gray silty clay with rock lenses
ft
ft.
ft.
ft.
21. REMARKS
MA 2 ti ZU13
--- - ,,, D rr, ,,,,,f04,,A,
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
22. a ification:
lla F ORMA f I N PROCESSING UNIT
03/12/13
Signature of Certi ed Well Contractor Date
By signing this oral, 1 hereby certib, 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 oj•ttzis record has been provided to tite 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, Raleig T rz. 6' '.-1
24c. For Water Supply & Injection Wells: In aedingthe form to
the address(es) above, also submit one copy o is form within 30 days of
completion of well construction to the county 1
where constructed. .`A
North Carolina Department of Environment and Natural Resources - Division of Water Quality
e? ' t}• .
...Reyiae .1an,_2013