412448_Well Construction - GW1_20130325

WELL CONST UCTION REC
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:
D Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
2l Irrigation
Non Water Supply Well:
❑Monitoring ❑Recovery
DMunicipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
D Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
D Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
4. DateWell(s) Completed: 02/28/13 Well ID#
5a. Well Location:
Steven Anderman
Facility/Owner Name
2599 Hillsborough Dr.
Facility ID# (if applicable)
Physical Address, City, and Zip
Brunswick
219JD024
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3.3'56.564 N 078'08.451
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
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: 00 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
1i
10. Static water Ievel below top of casing: 8 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4" (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:
41244
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
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
80, ft.
4„ in.
PVC
ft,
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
80' ft.
100' fte
2" in.-
.010
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
20' ft.
Bentonite
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, soillrock type, grain size, etc.)
0 ft.
45 ft.
Fine to med brn-tan sand
45 ft.
55 ft.
Gray med-coarse sand
60 ft.
120 ft.
Soft to hard limestone rock
120 ft.
260 ft.
Gray silty sands to very stiff gray clay with
ft
ft
rock lenses
ft.
ft.
ft,
ft.
21. REMARKS M . V' , 1 Z 0 i 3
WATER a E ER QUALITY SEG1 ION
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 50+ Method of test:
13b. Disinfection type: Amount:
22. Certitcation:
02/28/13
Signature of Certifi d Well Contractor Date
By signing this form, 1 hereby certi.fr 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.
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 Injection Wells: In addition to sending the form to the address in 24a
above, also submit a coy of this form within 3 _ o e of. '
construction to the following:
Division of Water Quality, Underground Inj;tion
1636 Mail Service Center, Raleigh
y,
24c. For Water Supply & Injection Wells: In ad`,: it on to sending the form to
the address(es) above, also submit one copy of t'i :form within 30 days of
completion of well construction to the county health department of the county
where constructed.
of trol Program,
N6V 2013
Off.
Form GW-1
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Revised Jan. 2013