410821_Well Construction - GW1_20130128

910 )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 215'
R
RESIDENTIAL WELL CONSTRUCTIOJ .REC®RD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2531A
1. WELL CONTRACTOR:
H. Michael Saae
Well Contractor (Individual) Name
AD lied Resource Manaaement. P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC
City or Town 28443
( 91027i0-2919
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# BCHD file #2012071064
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check Applicable Box): Residential Water Supply
PP Y l!�
DATE DRILLED 01 /17/13
TIME COMPLETED 2:00 AM ❑ PM [i(
4. WELL LOCATION:
CITY: SOUthDort COUNTY Brunswic
k
8682 Telegraph Rd. SE
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valle
Y CJJFIat DRidge DOther
LATITUDE 34 ° 4 0.1810 ►►
DMS OR DD
LONGITUDE 77 ° 58 ► 0.1780 " DMS OR
DD
Latitude/longitude source: VGPS
C]Topographic map
(location of well must be shown on a
USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
Belvedere Property Mamt. - Rick Hiabv Name
9149 Orton Road SE
Street Address
Winnabaw NC 28479
City or Town State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing: 14.5
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 1.5 FT. Above Land Surface"
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 150+ METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3a( 10%
NO Rf
FT.
Submit within 30 days of completion to: Division of tiVater Quality - information Processing,
Mali Service Center, Raleigh, NC 27699-161, Phone :Da
�9'6 9j 807-6300
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Top 170'
4-1,0321
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING: Depth Diameter Thickness/Weight Material
Top +1.5 Bottom 175' Ft. 6" SCH40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0. Bottom 25' Ft. Grout
Top 160' Bottom 170' Ft. Bentonite
Top BottomFt.
9. SCREEN: Depth Diameter
Top 175' Bottom 225'Ft.4" in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth
Bottom 225'
Top Bottom
Size
Ft. #2
Ft.
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom
0' / 52'
: 52' /65'
65' . / 125'
125' /170'
/ 225'
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12. REMARKS:
Method
Poured
Poured
Slot Size Material
•20 in. PVC
Material
Sand
Formation Description
Tan medium to Tight sand
Hard limestone rock
Fine to medium gray sands
Soft sandy limestone
Medium hard to soft limestone
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED T
141
O THE WELL OWNER,
SIGNATURE OF CERTIFIED WELL CONTRACTOR
-------- 01 /17/13
DATE
H. Michael Sa e
• —PRINTED
NAME OF PERSON CONSTRUCTING THE WELL
Form GW-la
ev. 2/09
-inforr c tinn