GW1-2022-01921_Well Construction - GW1_20220224

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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 110 f`• 120 rL
3465-A 160 ft• 200 f`
t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a .ble
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. j in.
Company Name 16.INNER CASING OR TUBING(geothermal closedaoo
2020-1399 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 f`' 103 f`• 6-1/4'' 1°• SDR21 PVC
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 50 ft. Bentonite poured
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. To MATERIAL EMPLACEMENTMEI'HOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft. &❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soi0rock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`• 8 f`• Orange Sand&Clay
4.Date Well(s)Completed: Well ID#
6-17-21 12 ft- 26 f`• Tan Sand&Gravel
26 f`• 35 f`• Gray Clay
5a.Well Location: 35 f`' 45 f`. Gray Sand
H&H Homes Lot 12
45 f`• 85 f`• Gray Clay
Facility/Owner Name Facility iD#(if applicable)
85 ft- 92 ft. Gray Sand
NC 28356 4211 Mc Bryde St, Linden, 92 ft- 200 f`• Gray Rock
Physical Address,City,and Zip 21 REMARKS I"
Cumberland 0563-97-8763 �-F. :_ " °M _ -
County Parcel identification No.(PIN) FEB 9 4 7027
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IaUlong is sufficient)
N W t� /K i ?v l t�tt• , 4.,, 1 aql I
Signa a 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 E]No copy ofthis 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 tinder 421 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-waler supply wells ONLY ivilhi the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200 (ft.) 24s. 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,
If waler level is above casing,use"+" 1617 Mail Service`Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" x 5.75" (in) 24b. For Infection Wells ONLY: in addition to sending the form to the address in
Mud Rotary 24a above, 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 20 Method of test: Blow 24c.For Water Supply&Injection Wells:
(gp ) 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