HomeMy WebLinkAboutWI0800077_Correspondence_20190509Central Files: APS _ SWP
5/9/2019
Permit Number WI0800077 Permit Tracking Slip
Program Category Status Project Type
Ground Water Active New Project
Permit Type
Injection Water Only GSHP Well System
Primary Reviewer
evan.kane
Coastal SWRule
Permitted Flow
Facility
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Facility Name
Teachey, Gary - SFR
Location Address
8713 Champion Hills Dr
Wilmington
Owner
NC 28402
Major/Minor Region
Minor Wilmington
County
New Hanover
Facility Contact Affiliation
Owner Name
Gary Teachey
Dates/Events
Owner Type
Individual
Owner Affiliation
Gary Teachey
8713 Champion Hills Dr
Wilmington NC 28402
Orig Issue
8/1/2000
Scheduled
App Received Draft Initiated Issuance Public Notice Issue Expiration
8/1/2000 8/1/2000 8/1/2000
Regulated Activities Requested /Received Events
Heat Pump Injection
Outfall
Waterbody Name
Streamlndex Number Current Class Subbasin
WELL CONSTRUCTION RECORD
'[his form can be used for single or mutiple wells
For Internal Use ONLY:
1, Well Contractor Information:
Chauncey Leggett
Well Contractor Name
MAY 232018
14. WATER ZONES
(FROM i TO DESCRIPTION
-t
ft. , ft.
_...- ft. ! ft. -
2269-A ,15.OUTER CASING (for multi -eased wells) OR LINER (if applicable)
NC Well Contractor Certification Number !FROM TO DIAMETER THICKNESS MATERIAL
ft. i ft. in. , i
ft. j ft. in. j
t _
t6. INNER CASING OR TUBING (geothermal closed loop)
2. Well Construction Permit #: W18-00077 ,FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pervnnts (ie County, State, Variance. etc ` 0 ft. 350 ft. 1 in. PVC plastic
r
3. Well Use: ft. ft. in.
1.17. SCREEN
1 IF ROM TO DIAMETER I THICKNESS SLOT SIZE MATERIAL
Injection I'I ft.l ft. in.I J. i
ft. ft. in. j I
'18.GBOUT
'FROM TO MATERIAL j_ EMPLACEMENT METHOD & AMOUNT
I I 0- ft. ` 350ft.1Settonite_slurry -__ 30__.___TremiePipe
i ft..l. — ft.+-
ft. ft. j
.19. SAND/GRAVE.. PACK (if applicable) _
FROM TO MATERIAL I EMPLACEMENT METHOD & AMOUNT
ft. i ft. i
-- - - - - -1-
ft.; ft.
ft.1 ft.
20. DRILLING LOG (attach additional sheets if neeessary)
FROM 4 TO ' DESCRIPTION (color, hardness, soil/rock type, grain size, etc)
• 0 ft. i 12 ft. i Cream Clay
12 MI 20 ft. j Gray Clay & Silt
20 ft. j350 ft.! Gray Granite
Physical Address, City, and Zip I ft. I
Orange e ft. r
1 ft.
County Parcel Identification No. (PIN) ft. 1 ft. I
ft. t ft.
21 REMARKS
Lake Valley Well Co., Inc
Company Name
dater Cur...
. sta I0r
'.tar.:
4. Date Well(s) Completed: 5/11/2018 Well ID#
5a. Well Location:
List all applicable well construction pertmits (ie County, Stale, Variance, etc.
Rachel Krummel
Facility/Owner Name Facility ID (if applicable)
1116 Holly Creek LN Chapel Hill 27517 Lot
5b. Latitude and Longitude degrees/minutes/seconds or decimal degrees:
{If +sell field, one lat/long is sufficient.)
35.890795 N-79.145636
6. Is (are) the well(s): Temporary
7. Is this a repair to an existing well: No
if this is a repair, fill out known well construction in/orntation and explain the nature of the
repair under '= 2/ remarks section or 017 the back of this Arm.
S. Number of wells constructed: 4
Far multiple injection or nun -water wells ONLY with the same construction, you can
submit one form.
0. Total well depth below land surface: 350
1•',;r multiple wells list all depths ifdifferent (example- 3@ 200'and 2 C /00)
N, Double 1" loop in each borehole. Grouted in with 3 sand to 1 barotherm
from botton back to the top. Total of each hole 30 sand to 10-barotherm
(ft.)
tit. Static water level below top of casing: (ft.)
;7 water level is above casing, use "
11. Borehole diameter: 6 (in.)
12. Well construction method: Rotary air
(i.e. anger, rotary, cable, direct push, etc.)
'FOR WATER SUPPLY WELLS ONLY:
'i3a. Yield (gpm):
•I3b. Disinfection type:
Fonn OW-1
HTH
22. Certificati n:
5/11/2018
Signature of erti t. ell Contractor Date
By signing!his,fo 7, I hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or 1 5A 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.
SUMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following!
Division of Water Quality, Information Procession Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addtion 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, Undergroun Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
Method of test: Air 24c. For Water Supph• Injection Wells: In addtion to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Amount: 12 completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan 2013