GW1-2021-01645_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: \J�®
Jonathan Kamionka � FR
I WATER ZONES
�p FROM TO DESCRIPTION
Well Contractor Name AO 160 ft 180 ft
3465-A ��K `j+ 1. \�VrTL 230 ft 260 ft•
NC Well Contractor Certification Number tOresB 15.OUTER CASING for mulfi cased wells OR LINER if a liable
a�co& o do\ FROM TO DIAMETER THICKNESS MATERIAL
Bills Well Drilling Co. {ocm 0.NIFt ft. ft. in.
Company Name 16.INNER CASING,OR TUBING "eothermal dosed-loop)
2020-1365 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 118 ff 6.25 it" SDR21 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
+1 ft 130 ft' 4 SCh40 PVC
3.Well Use(check well use): 17..SCREEN `.
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft ft in.
❑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
❑Irri tion 0 ft' 20 ft bentonite poured
Non-Water Supply Well:
❑Monitoring ❑Recovery 0 It. 130 ft. pel plug poured
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELTACK if appiiable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑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/mck type rain sae,etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 4 ft Red Sand&Clay
4.Date Well(s)Completed: Well ID#
2-26-21 4 ft- 56 ft Orange Sand&Gravel
56 ft• 100 1" Mixed Clays
5a.Well Location: 100 ft 118 ft. Green Rock
Gary Robinson Homes 118 ff• 260 ft Mixed Rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft
9058 Hawkins Rd, Linden, NC 28356
ft. tt
Physical Address,City,and Zip
21.REMARKS
Cumberland 0573-16-3567
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification*
(if well field,one IaUlong is sufficient)
N `t 2-26-21
Si urn of Certified Well ontractor ate
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and/hat a
7.Is this a repair to an existing well: ❑Yes or ONo 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 ofiltis 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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection 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 m 15 Method of test: blow 24c.For Water Supply&Injection Wells:
(gp ) 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