GW1-2022-01925_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 FR.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 36 f" 42 ft.
3465-A ft. ft r
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER Ifa "licabte
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. tt. ft.
in
Company Name 16.INNER CASING OR TUBING' eothermal closed loo
2021-226 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 36 ft 4 '" SOO PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
42 ft- 46 ft 4 1°' sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I MATERIAL
'"'
❑Agricultural ❑Municipal/Public 36 "' 42 f` 4 .032 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUP
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 25 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)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 25 ft. 46 ft. #3 Gravel Poured
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa'`
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soilfrock VM train size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt- 8 ft. Orange Sand&Clay
4-1-21 8 f` 42 ft. Orange Tan Sand
4.Date Well(s)Completed: Well ID#
42 ft• 48 ft. Black Clay
5a.Well Location: ft. ft
Caviness Land Lot 5 f. IL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1616 Lizzie Lou Ct, Hope Mills, NC 28348 ft. ft. PCMMIED
Physical Address,City,and Zip 21.REMARKS ' -._ - -
Cumberland 0421-42-3571 FFR 2 49
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ;-, e-'01
22.Certification: �� ��'' ��
(if well field,one lat/long is sufficient) ?,pn ey ��,M1,
N W 4-1-21
Signatu ofCertilied Well Contractor Date
6.Is(are)the well(s): (OPermanent 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 0No 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 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: 46 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
15 (ft.) Division of Water Resources,Information Processing Unit,
If svaier level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Mud Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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: Pumping 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013