GW1-2022-01922_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 110 f" 120 r` �
3465-A 160 ft. 200 ft-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased weN OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2020-1396 FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 102 ft' 6-1/4" i° SDR21 PVC
List all applicable ive/l permits(.e.County,Sale,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. m.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. fL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nonn-
❑h anon 0 ft. 50 bentonite' poured
Water Supply Well: tt. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control ft tL
20.'DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. g ft. Orange Sand&Clay
6-16-21 12 ft- 26 ft Tan Sand&Gravel
4.Date Well(s)Completed: Well ID#
26 ft. 35 ft. Gray Clay
5a.Well Location: 35 ft' 45 ft Gray Sand
H&H Homes Lot 13
Facility/Owner Name Facility #(if applicable) 45 1- 85 ft Gray Clay
ID
4221 Mc Bryde St, Linden, NC 28356 85 ft 92 ft• Gray Sand
ock
Physical Address,City,and Zip 92 ft 200 ft Gray R
21.REMARKS
Cumberland 0563-96-4986
County Parcel Identification No.(PIN) A 20'27
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: 6
(ifwell field,one lat/long is sufficient)
Signatyre of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 921 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 oyection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(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 uvater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"&5.75" (in) 24b. For Injection 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
(gpm) Method of test:20+ blow 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this fdrm 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