GW1--04462_Well Construction - GW1_20240730

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 160 ft. 180 ft.
3465 240 ft. 260 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased pills)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2403-0003 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 134 ft. 6-1/8 in' SDR21 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 9gesldential Water Supply shared 18.GROUT
.' i"_ i / pp y( ) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation • . 0 ft. ft
Non-Water Supply Well: .,,`` 25 bentonite pumped
❑Monitoring IL 3 // Recovery ft. ft.
Injection Well: ',}rt ft. ft.
-r,-.%N.
❑Aquifer Recharge �;,;::-A`Lr�r - ;,JIroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
CPA FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attaeh additional sheets inecessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain use,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. clay
6-27-24 5 ft. 20 ft. coarse sand
4.Date Well(s)Completed: Well ID#
20 ft. 24 ft. Red clay
5a.Well Location:
Jacob Dalton 24 ft- 49 ft. Gray clay
facility/Owner Name Facility ID#(if applicable) 49 ft. 69 ft. Red&White soft clay
69 ft. 80 ft. Soft Red Clay
2167 Josey Williams Rd, Erwin, NC 28339 80 ft. 110 ft Red&Gray clay
Physical Address,City,and Zip REMARKS
Hamett 055-61-8521 110-125 Soft gray rock
County Parcel Identification No.(PIN) 125-300 Gray&Black rock
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N 6-27-24
Sign 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 DNo 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#2l 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: 300 (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 2@100) construction to the following:
10.Static water level below top of casing: 50 (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 Injection 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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013