GW1-2022-01918_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 I DESCRIPTION
Well Contractor Name 36 ft. 42 fL
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. I ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loon)`
2021-228 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: LV +1 ft• 36 f° 4 1°' SCh40 PVC
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
42 ft' 46 ft 4 in. sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 36 rt. 42 ft. 4 in. 032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. bentonite poured
Non-Water Supply Well: fr. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMErHOD20 tr. 46 rt' #3 Gravel Poured
❑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/reck IyM emin size,ere
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fr. 5 ft. Orange Sand&Clay
5-14-21 5 ft. 46 fr. Tan&White sand
4.Date Well(s)Completed: Well ID# fr. ft.
5a.Well Location: ft. ft
Caviness Land Lot 32 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. u y
1434 Creekwood Rd, Hope Mills, NC 28348 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Cumberland 0421-32-5893
County Parcel Identification No.(PIN) tyt=r`•_ ::ir<i a
.F`^.t"i?•9�:i'�'d r._+...�.'C�:,.,tt,�ln-l.,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W 5-14-21
Si lure 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 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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#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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a//depths ifdijjerent(example-3 rt 200'and 2[@100') construction to the following:
10.Static water level below top of casing: 17 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
13a.Yield
(gpm) 20+ Method of test: bailed 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.
Fort GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013