GW1-2022-01916_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 i
FROM TO DESCRIPTION
Well Contractor Name 20 1" 26 ft.
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ap livable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loon)
2021-395/1211 FROM TO DIAMETER THICKNESS AL
MATERIAL
2.Well Construction Permit#: +1 It' 20 ft 4 1O I SCh40 PVC
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc.)
26 f`• 28 ft 14 '"' I SCh40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20 tt. 26 ft 4 in. .030 sch40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 18 ft. Bentonite poured
Non-Water Supply Well:
ft. ft.❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 18 ft' 28 ft. #3 Gravel Poured
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 8 f`• i Orange sand
4.Date Well(s)Completed: 6-9-21 Well ID# 8 ft. 12 ft Orange Clay
12 f`- 22 f`• Orange Sand
5a.Well Location: 22 ft' 28 ft Gray Clay
Caviness Land Lot 4 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
409 Kiki Dr, Fayetteville, NC 28312 ft. ft
Physical Address,City,and Zip 21.REMARKS }. � ,i q
Cumberland 0467-20-9727
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: P'=:ale fit ;
(if well field,one[attlong is sufficient) :++ �_ e-=
N w it/ `%C ty . .
V' .�I,. ..
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC'02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofihis record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair ender H21 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: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii Brent(example-3 rt 00'and 2 n/00') construction to the following:
10.Static water level below top of casing: 10 (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 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 Method of test: pumped 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