GW1-2021-01491_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 ��("j 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name Tx3Gl ICU 0 ft' 200 ft.
3465-A p�'� sg�n9 ft. ft.
NC Well Contractor Certification Number RQ10�o 15.OUTER CASING for rnulN-aised wells OR LINER if a licable
BIII's Well Drilling Co. �n�o� 30�Rse� FROM ft TO ft DIAMETER rn THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING iothermid closed-loop)"
2020-1276 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 It. 123 It• 6.25 i°• SDR21 PVC
List all applicable ivell permits(i.e.County,Stale,Variance,Injection,etc)
ft. ft in.
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) ElResidential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It' 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 applicable)
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 shafts if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soillroek type,gminsimetc-
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 It' 7 ft. Orange Sand&Clay
4.Date Well(s)Completed: Well ID#
2-25-2021 7 ft. 26 ft Orange Sand&Gravel
26 It• 115 It. Mixed Clays
Sa.Well Location:
115 It• 150 It. Green Rock
L. Robert Munoz
150 It• 200 It. Gray Rock
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3960 Toot St, Linden, NC 28356
ft.�­ft-
Physical Address,City,and Zip
21.REMARKS
Cumberland 0562-89-3138
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 2-25-2021
SiEKature 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 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to llte well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 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 ifdijferent(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,
Ifwaler 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) Method of test:
20+ blow 24c.For Water Supply&Injection Wells:
Also submit one copy of this tform 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