GW1-2021-01643_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: �C,sNS 1
Jonathan Kamionka '14.WATEIRZONES i
FROM TO DESCRIPTION
Well Contractor Name RLULI315 ft. ft.
3465-A AY sing U 50 ft. ft
NC Well Contractor Certification Number 1nf oftltatlon Plod ton 15.OUTER CASING for multi-eased wells OR LINER'if ii ticable
BIII's Well Drilling Co. pWR Sep FROM ft TO tL DIAMETER rm THICKNESS MATERIAL
Company Name 16:INNER CASING OR'TUBING eotheimal closed-loo`
2020-1485 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft- 209 fL 6 in. .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 I TO I DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic k ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL & rn.
'I GROUT.;.r� �ti..
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0
ft' 209 f` Bentonite pumped
Non-Water Supply Well:
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO rier ft. fr. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. f,
.20.DRILLING""LOG attach additional sheets if necess'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn soil/rock type,grain sht,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f` 12 ft Mixed Sands
4.Date Well(s)Completed: 1-19-2021 Wel1ID# 12 f` 203 ft Sand&Clay layers
103 f` 209 f` Black&Brown Rock
5a.Well Location:
Shane Taylor 209 f`• 315 fa Black, brown&red rock
Y 315 ft- 335 ft Gray Rock
Facility/Owner Name Facility ID#(if applicable) 335 f`• 350 ft. Dark Gray Rock
1965 John McMillian Rd, Hope Mills, NC 28348 350 rt• 360 ft Black&Red Rock
Physical Address,City,and Zip
'21.REMARKS. - is _k =- " '. , .'
Cumberland 0421-88-6651 360-420 Dark Gray Rock
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifw sufficient)
ell field,one lat/long is sucient)N /
�, 1-1-2021
Sign of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 0N0 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 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: 420 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b. For Iniection Wells ONLY.: In addition to sending the form to the address in
Air& Mud Rotary 24aabove, 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) 38 Method of test: blow 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