GW1-2021-01494_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 200 ft. 218 ft
3465-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wdIs OR LINER if a ficable
FROM TO DGIMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING: eothermA closed-loop)
2020-1192 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 138 ft- SDR21 in' 6-1/4 PVC
List all applicable%veil permits(.e.County,State, Variance,Injection,etc)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft 'm
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(sin(single) fa ft in.
❑Industriat/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METBOD&AMOUNT
DIrrigation 0 ft. 20 ft bentonite poured
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck in size,ett
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft Orange Sandy Clay
3-25-21 5 ft- 114 ft- Mixed Clays
4.Date Well(s)Completed: Well ID#
114 ft- 138 rt. Soft Green Rock
5a.Well Location: 138 ft 218 ft Green&Gray Rock
Precision Custom Homes ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2995 Slocomb Rd, Linden, NC 28356
ft ft +�
Physical Address,City,and Zip 21 REMARKS
Cumberland 0562-85-6548 2 9 zoll
County Parcel Identification No.(PIN) PrAUnit
. r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: trt�cln'%3 t ct"011
(if well field,one lat/long is sufficient) R�e
N W
SignfjfeofCertifiedWell Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the%vell(s)%vas(were)constructed in accordance
with I SA NCAC 01C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been providedro the%veil owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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-%voter supply%vells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 218 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3@200'and 1@I00) 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
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11.Borehole diameter: 6 (in.) 24b.For Infection 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 m 10 Method of test: air 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this fortn 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
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