GW1-2022-01931_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:
14.Jonathan Kamionka FROM ER ZONES
FROM TO DESCRIPTION
Well Contractor Name 36 42 ft
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft• Ift. in.
Company Name 16.INNER CASING OR TUBING. eothermal closed-loop)
2021-227 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 36 ft' 4 1° Sch40 PVC
List all applicable well permits(i.e.County,Slate,Variance,hjeclion,etc)
42 ft• 46 It- 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 ft• 42 ft' 4 in. .032 SOO PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft. Bentonite poured
Non-Water Supply Well:
❑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 20 ft- 46 ft. #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/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Orange Sand&Clay
5-14-21 5 ft. 30 ft. Tan&White Sand
4.Date Well(s)Completed: Well ID# 30 ft. 36 ft. Gray Clay Layers
5a.Well Location: 36 ft• 46 ft Gray Sand
Caviness Land Lot 6 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. +^
1612 Lizzie Lou Ct, Hope Mills, NC 28348 ft. ft. s :
Physical Address,City,and Zip 21 REMARKS
Cumberland 0421-42-2535 `
County Parcel Identification No.(PIN) r_ V
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: s �an 'd F( 1;j"..n .'ri fr
22.Certification:
(if well field,one lat/loug is sufficient)
N W 5-14-21
Signat 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
wilh I5A 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 EINo copy of this record has been provided to fire well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 911 remarks section or on the back ofdiis 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 will;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 ifdijferent(example-3 a 200'and 2Q100') construction to the following:
10.Static water level below top of casing: 17 Division of Water Resources,Information Processing Unit,
If,vaier level is above casing,use 1.+1. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
Mud Rota 24aabove, 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 m 20+ Method of test: pumped 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.
Foot GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013