GW1--04488_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 300 ft. 400 ft•
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if apptieabie)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-141 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 246 ft• 6 in. .188 steel
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) —
1 ft. 305 ft. 4 in. sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLAMETER . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
ft. ft. in.['Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 246 ft. bentonite pumped
Non-Water Supply Well:
0 ft• 305 ft. bentonite poured
['Monitoring ❑Recovery _
Injection Well: ft. ft.
[Aquifer Recharge ❑Groundwater Remediation 14.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 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. 60 ft• sand
4-29-24 60 ft• 230 ft. Red &Gray Rock
4.Date Well(s)Completed: Well ID/4
230 ft• 280 ft• _ Hard Red Rock
5a.Well Location: 280 ft• 520 ft. Gray Bock
Turnkey MHP ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
2739 Turnkey Dr, Fayetteville, NC 28312 rt. ft.
Physical Address,City,and Zip :74 ti-4 :k tt
Cumberland 0464-92-2339 21.REI�A1ucs DA-,C.' , `'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N N, 4-29-24
Si ure 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 ElNo 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: 520 (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: 150 (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
20 pumped 24c.For Water Supply&Injection Wells:
Method of test:13a.Yield(gpm) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 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