WI0800401_WELL CONSTRUCTION RECORD_20141112

RM Project Number: 1730 River Drive Professional Heating & Air Pagel
Driller: Christopher Blackmon
Date Drilled: Loop No. Loop Depth GPS Coordinates
10/27/2014 1 300 34 45 00.5 76 44 38.6 RECEIVED/DENRIDWR
10/28/2014 2 300 34 45 00.4 76 44 38.5
10/29/2014 3 300 34 45 00.3 76 44 38.8 NOV 12 2014
10/29/2014 4 300 34 44 59.9 76 44 39.3
10/30/2014 5 300 34 45 00.7 76 44 38.5 Water Quality Re.
Operatic '.

WELL CONSTRUCTION RE IVPDiDE1^Ii1 R
form can be used for sie or multiple wells
1. Well Contractor Information:
Harry M. Sage
Well Contractor Name
2531-A
NC Well Contractor Certification Number
Applied Resource Management, P.C.
section
Company Name
2. Well Construction Permit #: N/A
List all applicable well construction permits (Le. Caunty, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricuitural
DGeothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
0Irrigation
❑Municipal/Public
❑Residential 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
LiGeothermal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 10/27/14 Well ID# N/A
5a. Well Location:
Mary -Lynn Osteen
N/A
Facility/Owner Name Facility iD1 (if applicable)
1730 River Drive, Morehead City, NC 28557
Physical Address, City, and Zip
Carteret 637720716620000
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
See Attached N See Attached
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Ls this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction information and explain the nature oldie
repair under 1121 remarks section or on the bac.of this form. ,)
J ^ 78. Number of wells constructed: 6 1-5 1f eutfr'f-Lli 7,>
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: 300
(ft.)
For multiple wells list all depths ifdifferent(example- 3 ,200' and 2@100')
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "n "
11. Borehole diameter: 8" (in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, direct push. etc.)
For Internal Use ONLY:
RECEIVED/DENN, <..
14.ZONES N O V 1 Z n 14
WATERFRO
TO
DESCRIPTION
ft.
ft
WatPr Quality Regional
ft.
ft
Operations Section
15. OUTER CASING (for meld -cased wells) OR LINER (if ap icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 fL
+/- 300 ft
1 in.
HDPE
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft
ft
in.
ft,
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT M ETHOD & AMOUNT
0 ft
300 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 (solar, hardness, soil/rock type, grain size, etc)
0 ft.
45 ft
White medium to fine sand
45 ft
75 ft•
Gray clay and shell
75 ft
130 ft
Green marine clay
130 ft
155 ft.
Very soft clay limestone mix
155 ft
260 ft
Medium hard sandy limestone
Gray medium to fine sands
260 ft
305 ft.
ft.
ft.
21. REMARKS
kArZNO0 Li 'I
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A Method of test: N/A
13b. Disinfection type: N/A Amount: N/A
22. Certification:
Siltdretur�Ce
149
ed Weil Contractor
/f) //i/`7
Date
By signing this form, 1 hereby certify that the wells) was (were) constructed in accordance
with 1SA 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.
Site diagram or additional well details:
ou 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 INSTUCTJONS
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 Iniection 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, Raleigh, NC 27699-1636
24c. For Water SuDDIv & 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 Resources - Division of Water Quality Revised Jan. 2013