WI0700308_Supporting documents_20210730

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2412A
1. WELL CONTRACTOR:
Donald H. Cummings
Well Contractor (Individual) Name
Applied Resource Management, P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town State Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W10700308
OTHER ASSOCIATED PERMIT#(n applicable)
SITE WELL ID #tit applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial p Agricultural 0 Recovery 0 Injection 5(
IrrigationD Other 0 (list use)
DATE DRILLED 12/4/12
4. WELL LOCATION:
518 Hollywood Blvd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Havelock COUNTY Craven
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Flat ❑Ridge ❑Other
LATITUDE 34 ^ 51 34.8200 "DMS OR DD
LONGITUDE 7( 21.2500 "DMS OR DD
Latitude/longitude source: QGPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (If applicable)
Street Address
City or Town State Zip Code
Airtech Mechanical
Contact Name
153 Two Lakes Trail
Mailing Address
New Bern
City or Town
(252 ) 636-5841
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 165'
NC 28560
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
NO ce/
c. WATER LEVEL Below Top of Casing: 11 FT.
(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 (gem): 60 METHOD OF TEST Airlift
f, DISINFECTION: Type HTH Amount 3p@10%D
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 1.5+ Bottom 135' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0' Bottomi2ar Ft. Grout Poured
Top 125' Bottom 130' Ft. Bentonite Poured
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 135' Bottom 165' Ft. 2" In. .020 in. PVC
Top Bottom Ft. In. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 130' Bottom 165' Ft. #2 sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0' / 80' Sands / Clayey sands
80' / 120' Clay
120' / 170' Sand / Large shell
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
D HAS BE P OVI EDT E WELL OWNER.
12/4/12
SIGNATURE OF CERTIFIED WELL RAC fOR DATE
Donald H. umminas
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09

NONRESIDENTIAL
North Carolina Department of Environment an
WELL CONTRACTOR CERTIFICA
1. WELL CONTRACTOR:
Donald H. Cummings
Well Contractor (Individual) Name
Applied Resource Management P.C.
Well Contractor Company Name
257 Transfer Station Rd.
Street Address
Hampstead NC 28443
City or Town Slate Zip Code
(910 ) 270-2919
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# W 10700308
OTHER ASSOCIATED PERMIT#(ifapplicable)
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigationp Other [(list use) SuooiV
DATE DRILLED 12/5/12
4. WELL LOCATION:
518 Hollywood Blvd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Havelock COUNTY Craven
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley UrFlat ❑Ridge OOther
LATITUDE 34 ° 51 36.0200 "DMS OR
LONGITUDE 7(j ° 54 ' 19.7500 "DMS OR
DD
DD
Latitude/longitude source: WPS DTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town
Airterh Mechanical
Contact Name
153 Two I ekes Trail
Mailing Address
New Bern
City or Town
(252 ) 636-5841
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 170'
State Zip Code
NC 28560
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ci
c. WATER LEVEL Below Top of Casing: 11' FT.
(Use "+' if Above Top of Casing)
WELL CONSTRUCTION RECORD
d Natural Resources- Division of Water Quality
TION# 2412A
d. TOP OF CASING IS 1.5+ FT. Above Land Surface`
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): 50 METHOD OF TEST Airlift
f. DISINFECTION: Type HTH Amount 3p(p?1o%
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7, CASING: Depth Diameter Weight Material
Top 1.5+ Bottom 140' Ft. 4" sch40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0' Bottom 23' Ft. Grout Poured
Top 125' Bottom 130' Ft. Bentonite Poured
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 135' Bottom 165' Ft. 2" in. 020 in. PVC
Top Bottom Ft. in.
in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 130' Bottom 165' Ft. #2
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0' / 80'
80' / 120'
120' / 170'
12. REMARKS:
Material
sand
Formation Description
Sands / Clayey sands
Clay
Sand / Large shell
1 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. ROVIDED TO WELL OWNER,
O
SI A U E OF CERTIFIED WELL C
12/5/12
CTOR DATE
Donald H Cummings
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09