GW1-2022-01913_Well Construction - GW1_20220224

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 220 ft- 240 fL
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitesed wells OR LINER rf
FROM a '6eable
TO THIC
Bill's Well Drilling Co. rt. ft. DIAMETER in. KNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eothermaI closed-loop)
2020-1191 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 129 1- 6-1/4" 'n' I SDR21 PVC
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc)
ft. ft in.
3.Well Use(check well use): 17.SCREENr
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic fL ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑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.SANDIGRAVEL PACK(if a "licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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,soillroek bqw,grainSim ttc.
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft Topsoil
5-25-21 1 ft. 100 1,- Clay Layers
4.Date Well(s)Completed: Well ID#
100 ft- 115 ft- Soft Rock
5a.Well Location:
115 ft• 129 ft' Gray Rock
Precision Custom Homes 129 ft 240 ft Hard Gray Rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2965 Slocomb Rd, Linden, NC 28356 ft. ft
Physical Address,City,and Zip 21 REMARKS
Cumberland 0562-85-6548 "
County Parcel Identification No.(PIN) FEB
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient) LN*
';y Si ature of Certified Well Contractor ate -
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)ivas(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 ElNo copy of this record has been provided to the ivell 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 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: 240 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii fereni(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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(gpm) 10 Method of test: air 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