414879_Well Construction - GW1_20130729

For Internal Use ONLY:
'114379
14. WATER ZONES
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Christopher Blackmon
Well Contractor Name
4145-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (i.e. County, State, Parimsce, etc.)
3. Well Use (check well use):
FROM
TO
DESCRIPTION
ft.
ft.
R.
15. OUTER CASING (for multi -eased wells) OR LINER (if
1' bl )
FROM
TO
D1AMETElt
aps
P ca e
Sch40 PVC
THICKNESS MATERIAL
+1.5 ft
250 ft
4
ta.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
in.
ft.
ft.
in.
17. SCREEN
Water Supply Well:
DAgricultural
aGeothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
OMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
°Recovery
Injection 'Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
DAquifer Test
DExperimental Technology
DGeothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
4. Date Well(s) Completed: 6/6/13
°Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
❑Subsidence Control
°Tracer
°Other (explain under#21 Remarks)
Well ID# N/A
John Lyle
Facility/Owner Name , Facility ID# (if applicable)
402 Creedmoor Road, Jacksonville, NC 28546
Physical Address, City, and Zip
Onslow
053267
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one fat/long is sufficient)
34 45.971 N 077 21 33.4
6. Is (are) the well(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: DY es or DNo
If this is a repair, fill out known well construction information and explmis the nature of the
repair under #11 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or nos-waier supply wells ONLY with the saute construction, you can
submit one form.
9. Total well depth below land surface: 290 (ft)
For multiple wells list all depths if different (example- 3Q200' and 2@100')
10. Static water level below top of casing: 35 (ft.)
If water level is above casing, use '4
11. Borehole diameter- 8 _... _. _ _ _.(in.)
12. \hell construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc)
FOR WATER SUPPLY WELLS ONLY:
13a. yield (gpm) 70 Method of test: Airlift
13b. Disinfection type: HTH Amount: 3 Ibs
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATFRISI
250 ft.
270 ft
4
in.
.010
sch40
PVC
270 ft.
290 ft
4
im
020
sch40
PVC
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
240 '
Bentonite
Poured
£t.
ft.
ft.
R.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
240 ft
290 ft-
Sand
Poured
ft.
20. DRILLING LOG (atta h additional sheets if necessary)
FROM
ft
TO
50 ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
Heavy clays
50 ft.
105 ft
Soft rock with grey clay
105 ft
247 ft
Grey clay with grey fine sand
247 ft.
265 ft
Very sandy limestone
264 rt.
289 ft-
Sandy limestone
289 ft
ft.
291 ft
Sandygrey clay with limestone streaks
4 ail
21. REMARKS
aa, I t R QUAD) Y SECTI()I
tidrelrr nannl.; .7P2(;i;C:; ;ItJC UtJR:
22. Certification:
e
i51j
Signature ofCertified Well Contractor Date
By signing this form, I hereby cere(' that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or 15,4 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 rimy 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 copy of this form within 30 days of completion of well
construction to the following:
Ii f• ' V f7 Y6 h` ra
Division of Water Quality, Undergrou Uijec on1Cbntro fOgras
1636 Mail Service Center, R� h, N��Cg g2g76999,tt-1636
24c. For Water Supply & Injection Wells:!Utfjadditi lz sendmgZl "fdnn
the address(es) above; also submit one coprr 'bf this form within 30 days_
completion of well construction to the comity health department of the county
v there constructed.
Fonu GW-I
North Carolina Department ofEnvironment and Natural Resources -Division of Water Quality
Revised Ian. 2013