GW1-2021-01641_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka 14.WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name 88 ft. 94 ft.
3465-A ��� e. e.
NC Well Contractor Certification Number �� 9 Lo�1 15.OUTER CASING for multi-cased wells OR LINER rf a "ficable
BIII's Well Drilling Co. Sg1�U^l` FROM ft TO ft
DIAMETER'S THICKNESS MATERIAL
Company Name p �O V S�100 16.INNER CASING OR TUBING eothermal dosed-loo
2020-�V DW FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V +1 rt- 88 ft. 4 1 L sch40 PVC
List all applicable ivell permits(i.e.County,State, Variance,injection,etc)
94 ft• 98 ft 4 in. sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 88 It' 94 IL 4 1n. .032 SCh40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) OResidential Water Supply(single) ft. ft. is
( g/ g PP Y) PP Y( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft- bentonite poured
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK i a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Storrnwater Drainage 20 ft 98 tt #3 Gravel Poured
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock rain size etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 8 h• Orange Sandy Clay
1-11-2021 8 ft- 26 ft. Mixed Sands
4.Date Well(s)Completed: Well ID#
26 ft- 49 ft. Clay
5a.Well Location:
H & H Homes Lot 27 49 tt• 54 ft. Sand
Facility/Owner Name Facility ID#(if applicable) � It- 66 ft Clay
Hope Mills, NC 28348 66 ft- 88 ft. Gray Sandy Clay
321 Gadson Dr, Ho
P 88 ft- 98 ft. Sand
Physical Address,City,and Zip
21.REMARKS
Cumberland 0412-63-0418
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification•
(if well field,one lat/long is sufficient) /
N W L// 1-11-2021
Sign re of Certified Well Contractor Date
6.Is(are)the well(s): 21"ermanent or ❑Temporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with/SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well oivner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS'
9.Total well depth below land surface: 98 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifili ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 8 (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Mud Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20+ Method of test: balled 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 1 Cup well construction to the county'health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013