GW1--04492_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 140 ft. 200 ft-
3465-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if applkable)
FROM TO DIAMETER THICKNESS MATERIAL
ft Bill's Well Drilling Co. . ft. ' in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-bop)
2023-173 FROM _ TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 fr 114 ft 6-1/ 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) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT_
❑Irrigation 0 fr. 24 ft. bentonite pumped Non-Water Supply Well: —It.
OMonitoring ❑Recovery
Injection Well: .— 4 yA...= i ft. ft. _
❑Aquifer Recharge ❑Groundwater Rerfl diation` •19.SAND/GRAVEL PACK(if applicable)
'N FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier y \ 3 u ft. ft.
❑Aquifer Test ❑Stormwater Drainage ;•)•st •
❑Experimental Technology ❑Subsidence Controk "'t r r'r k' ft. ft.
it C• Gm
Dr fti t�'pw 20.DR1t.t.INC LOG(attach addidoual sheets&aeceasary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft. 8 ft. mixed clay
3-12-24 8 ft. 10 ir. orange sand&gravel
4.Date Well(s)Completed: , Well ID#
10 ft. 28 ft. Hard Gray Clay
5a.Well Location: 28 ft 35 ft Gray Sand&clay
William Collier 35 ft. 90 ft. Gray Clay
Facility/Owner Name Facility ID#(if applicable) 90 it 97 rr. Gray Sand
5370 Indian Ridge Rd, Linden, NC 28356 97 ft. 105 fr. Gray Clay
Physical Address,City,and Zip
21.REMARKS
Cumberland 0583-36-3090 105-200 Gray Rock
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifcation•
(if well field,one lat/long is sufficient)
N w 3-12-24
Signe of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA 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 d21 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: 200 (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 4200'and 2 rt 100') construction to the following:
10.Static water level below top of casing: 52 (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
24a above, also submit a copy of this form within 30 days of completion of well
Mud &Air Rotary
12.Well construction method: 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 blow 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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