414520_Well Construction - GW1_20130708

WELL CONSTRUCTION RECORD
This fort can be used for single or multiple wells
I. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
Company Name
2.Well Construction Permit #: EWP2013-00384
List all applicable well construction permits (i.e. County, Stale, Variance, etc)
3. Well Use (check well use):
For Internal Use ONLY:
4 1 4520
19. WATER ZONES
FROM
TO
DESCRIPTION
6
ft
65 ft.
Surficial
ft.
ft.
15. OUTER CASING (for multi -eased wells) OR LINER (if apcae libl )
FROM
+1.5 ft
TO
25 ft.
DIAMETER
6
in.
p
MATERIAL
SCH40 l PVC
THICKNESS
16. INNER CASING OR TUBING (geothermal deed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
ft.
ft.
to
17. SCREEN
Water Supply Well:
°Agricultural
❑Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irrigation
°Municipal/Public
BResidential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring °Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
°Groundwater Remediation
°Salinity Barrier
OStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under 421 Remarks)
4. Date Welt(s) Completed: 6/14/2013µ,ell ma Well #2
5a. Wen Location:
ONWASA
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
25 ft.
65 ft
6 5/8 i°'
.010
SCH40
PVC
ft.
ft.
is
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0
ft.
23 ft.
Bentonite
Pouted 22 - 55 lb bags
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
22 ft.
65 ft.
Silica #2
Poured
ft.
20. DRILLING LOG (aaa h additional sheets if necessary)
FROM
0
ft.
TO
6
ft.
DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
Reddish brown sandy clay
6
ft.
9
ft.
Limestone caprock
9
Sand, rock, shell. mix (marl)
Facility/Owner Name Facility ID# (if applicable)
189 Mills Field Road, Richlands, NC 28574
Physical Address, City, and Zip
Onslow
017944
County Parcel Identification No. (PIN)
513. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
�'y, 5 z. ' )7 N n'77, sf; 70Z_
6. Is (are) the well(s): °Permanent or OTemporary
7. Is this a repair to an existing well: °Yes or BNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2J remarks section or an the back of this farm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same consfrucdoa, you can
submit one form.
9. Total well depth below land surface: 65
For multiple wells list all depths fdlfferenl (example- 3@200' and 2C1001)
(ft)
10. Static water level below top of casing: 5 (ft.)
If water level is above casing, use '4 "
li. Boreholediametee. 10 (in:)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
35
ft:'
65 ft.
Gray fine sand to silty sands
ft.
ft.
ft.
1t.
J'JI !k 2 IUIJ
21. REMARKS
NA1'CR QUALITY SECTION
INrnRd,ArIoN PROCESSING UNIT
22. Certification:
gva"tme of Certj$ed Well Contractor
Date
By signing fin srform, 1 hereby certify that fie well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A. NCAC 02C,0200 Well Constnscion Standards and that a
copy of this record has been provided to thehelbwner
a.
23. Site diagram or additional wen details: (• lj
You may use the back of this page to: providenQQtrio f[?vvel detadsor well
construction details. You may also attach; additionitpa eMif� aiy. it
SUBMITTAL INSTUCTIONS .i La)
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 Mall Service Center, Raleigh, NC 27699-1617
-24b.. For. Irritation -WCUS:—In ad,.a:•ion-tosending{Ise-fern-to-the-addrossn-2Aa ._._...
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) 25 Method of test: Airlift
13b. Disinfection type: HTH Amount: Pound
Division of Water Quality, Underground Injection Control Program,
1636 Mail Senice Center, Raleigh, NC 27699-1636
24c. For Water Supnlr & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environment and Natural Resmnces— Division of Water Quality Revised Jan. 2013