GW1-2021-01644_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: 14.WATER ZONES
��`'�®
Jonathan Kamionka ��� V f
FROM TO DESCRIPTION
t �-
Well Contractor Name (� 230 r`• 260 fL ,
3465-A �Y u \P ft. ft.
NC Well Contractor Certification Number pro 15.OUTER,CASING for muldtas'ed'wells OR LINER if a bcable
BIII's Well Drilling Co. ��Rorma��RSg�r°� FROM rt TO rL DNMETERrn THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eothermaI closed-loop)
2020-1366 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 rt• 123 rt• 6.25 1°' 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
ft
fL in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 ft- bentonite poured
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILL LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnei%soil/rock type,Krain sae etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 4 ft. Red Sand&clay
4.Date Well(s)Completed: 3-3-21 Well ID# 4 rL 56 ft. Orange Sand&Gravel
56 ft 100 ft• Mixed Clays
5a.Well Location:
100 f° 120 rt. Green Soft Rock
Gary Robinson Homes 120 rt 260 ft. Gray&Red Rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft
9050 Hawkins Rd, Linden, NC 28356 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Cumberland 0573-16-4543
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 W 3-3-21
Si tore of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill our known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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. 260 (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@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
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
13a.Yield(gpm) 10 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013