GW1-2021-01642_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 i`� 14.WATER ZONES
!:!, FROM [280
O DESCRIPTION
Well Contractor Name 200 ft' 00 ft.
3465-A PAR 2 9 202� Vn 240 f fr.
NC Well Contractor Certification Number egg\R9 15.OUTER CASING for multi eased wells OR LINER if a cable
nP(O n FROM TO DIAMETER `THICKNESS MATERIAL
Bill's Well Drilling Co. yolfr.a`�RSedc'0 ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-too
2019-75 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 195 fc 6 1O' .188 Steel
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENr METHOD&AMOUNT
❑Irrigation 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 if applicable)
EMP
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL LACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
fr. fa
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soft/mck tyM gnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Topsoil
4.Date Well(s)Completed: 12-30-2020 Well ID# 1 ft- 4 ft. Orange Clay
4 ft. 190 ft. Mixed Gray Clay
5a.Well Location:
Gary Robinson Homes 190 It- 300 fL Gray Rock
ry u. rL
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
7550 Hillside Ave, Fayetteville, NC 28311
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Cumberland 0542-26-9056
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one[at/long is sufficient)
N W
12-30-2020
Sign4lfr=of Certified Web Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby certify that the,vell(s)ivas(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known ivell construction information and explain the nature of the
repair tinder#2I 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 wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 177 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service',Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air& Mud Rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 ServicelCenter,Raleigh,NC 27699-1636
13a.Yield(gpm)
15 Method of test: blowing 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013