GW1--04489_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD For Internal Use ONLY:
_Lillis form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 260 ft. 280 ft.
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)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) i
2024-00616 FROM TO DIAMETER THICKNESS MATERIAL -
2.Well Construction Permit#: +1 ft. 228 ft. 6 1n. .188 Steel
List all applicable well permits(r.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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation L 0 ft. 20 ft. bentonite pumped
Non-Water Supply Well: ' f —
t. ft.
❑Monitoring ❑Recovery ? U t -
Injection Well: t, ft. ft.
❑AquiferRecharge ❑GroundwateIRerr4diatiod"'-,.y�'-I 11�SAND/GRAVEL PACK(if applicable)
itrier h..r;s FROM TO . MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier d ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Sandy clay
5-10-24 9 ft. 20 ft. Sand&Gravel
4.Date Well(s)Completed: Well ID#
20 ft. 35 ft. Light Gray Clay
Sa.Well Location: 35 ft- 145 ft. Gray Clay
Kimash Homes
Facility/Owner Name Facility ID#(if applicable) 145 ff. 155 ft. Sandy clay
155 ft. 170 ft. Gray clay
3872 Gainey Rd, Fayetteville, NC 28306 170 ft. 205 ft. Weathered Rock
Physical Address,City,and Zip 21.REMARKS
Cumberland 4549-16-8810 205-220 Soft Rock
County Parcel Identification No.(PIN) 220-300 Black 7 Red Rock
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifcation:
(if well field,one IaUlong is sufficient)
N W 14Y/ 5-10-24
Signat 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 ❑No 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: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdijferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 89 (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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013