GW1--04454_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD
Inns form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information:
Jonathan Kamionka 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 140 ft. 180 h'
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.(for mtdtl-eased wells)OR LINER(If aRQgc*b)p)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft I in. I -
Company Name I6.INNER CASING OR TUBING(geothermal closed-loop)
2023-67 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft117 it 6-1/8 in — —
List all applicable well permits(i.e.County,State,Variance,Injection,Lc.) SDR21 PVC
ft. ft. in.
3.Well Use(check well use):
17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1(l.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
❑Irrigation
Non-Water Supply Well: 0 ft' 25 it. bentonite pumped
❑Monitoring ❑Recove ry ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
—
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets ifnecessary)❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION(color,hardness,soiVreck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 11 ft. clay
4.Date Well(s)Completed: 9-22-23 Well ID# 11 ft. 25 ft. White Sand&gravel
25 ft. 97 ft. Grayclay
5a.Well Location: _
Jason Brown 97 ft• 117 f• Gray Rock
117 ft. 180 ft. Gray Rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
7833 Lucinda Ln, Linden, NC 28356 ;
ft. ft. . .�.•..► ' tf �-..
Physical Address,City,and Zip 21.REMARKS I ,
Cumberland
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi cation: _t/.
(if well field,one lat/long is sufficient) _ _
N W 9-22-23
".__,ee_f(r_z__,__..,Z.------
Sign a oe o Certified Well Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A 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: 180 (ft.) 24a. 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 1@l00') construction to the following:
10.Static water level below top of casing: (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: 5.75 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Mud &Air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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: blow 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 OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013