GW1-2021-01496_Well Construction - GW1_20210429

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 c
FROM TO I DESCRIPTION
Well Contractor Name 340 ft' 360 ft'
3465-A r'SCS` ft. ft.
NC Well Contractor Certification Number q g 2011 15.OUTER CASING for muld-rased'wells OR LINER rf a 'Gcable
FAR D FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
16.INNER CASING OR TUBING eothermal closed-loo
Company Name 2020-1 ,D�NR S FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 301 ft 6 1O .188 steel
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc)
ft. ft. is
3.Well Use(check well use): 17.SCREEN.,
Water Supply Well:
FROM ft. TO ft. DIAMETER R SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. _in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 301 ft- bentonite pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.'SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑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- 3 ft Orange sandy clay
4.Date Well(s)Completed: 3-1 1-21 Well ID# 3 1- 25 ft Orange Sand
25 ft- 50 ft. Gray Clay
5a.Well Location: 50 It.
70 ft. Gray Sand&Wood
Micheal Mingo 70 ft- 230 ft Gray Clay w/sand streaks
Facility/Owner Name Facility ID#(if applicable) 230 ft' 290 ft Red clay&rock layers
8746 Tabor Church Rd, White Oak, NC 28399
290 ft• 380 ft Gray&Red Rock
Physical Address,City,and Zip 21.REMARKS
Cumberland 0460-02-1158
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one[at/long is sufficient)
N W 3-11-21
Signa)fire of Certified Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this farm,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under i121 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
S.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: 380 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+ ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air& Mud Rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 40 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.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013