GW1--04481_Well Construction - GW1_20240730

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
1This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka 14"WATER ZONES
FROM TO DESCRIPTION
eWll Contractor Name 56 ft. 62 ft.
1
3465-A ft" ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wiells)`ORL1NER(lf applkab1E) ,
FROM TO DIAMETER THICKNESS ll MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2021-00111 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 fr• 56 ft. 4 1° sch40 PVC
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
62 ft- 66 ft- 4 in. sch40 PVC
3.Well Use(check well use): 17.6CREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 56 ft" 62 ft" 6 in. .032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) 11Residential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 25 ft" bentonite poured
Non-Water Supply Well: ft. ft. —
❑Monitoring ❑Recovery _
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)_
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier _25 ft. 66 ft' #2 gravel poured
❑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,soiVrock type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Gray Sand
15 ft" 20 ft. Clay
4.Date Well(s)Completed: 12-1-23 Well ID#
20 ft 66 ft- Gray Sand&Wood
5a.Well Location: ft. ft.
Caviness&Cates Building&Development Lot 251
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. + J'4..��
V
6837 Running Fox Rd, Hope Mills, NC 28348 ft. ft. ' I�'
Physical Address,City,and Zip 21.REMARKS z4. s ','
Cumberland 0412-42-00920
County Parcel Identification No.(PIN) IfAr6C%Is"i'r l " i t k
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient) // .______
N N 12-1-23
Si tore 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 I5A 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 EINo 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: 66 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 15 (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: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Mud 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 bailed 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013