GW1-2021-04353_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 Kamiona 14.wATERZONEs ,
t FROM TO DESCRIPTION
Well Contractor Name $0 ft. 90 ft. 100-110
3465-A cj� tLp'L� 13 `eft 150 ft
NC Well Contractor Certification Number . UTER CASING for multi cased wells OR LINER'if ap ticable
��� O���ej OM ft. TO ft. DIAMETER in. TRICKINESS MATERIAL.
Bill's Well DrillingCo. pQ ,
16.INNER CASING OR TUBING `eothei oral dosed-loo"
Company Name 05 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1.11P
t-80 ft. 10-ta0 ft 4 in. sch40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection, 1c)
tp•13O ft. ISO_b o ft "'4 ' SCh40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public OIn f ft Lao- ft 4 1°' .032 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 110 ft. 1 5O ft 4 1° .032 SCh40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
2Irrigation 0 ft. 20 rt bentonite poured
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK if ii livable
FROM TO MATERIAL EMPL.ACEMENTMEI'HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
20 ft' 160 ft. #3 Gravel Poured
❑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,sod/rack tyM grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt. 20 ft Brown Sand&Clay
3-19-21 20 ft 60 ft Gray Clay
4.Date Well(s)Completed: Well ID#
60 ft- 65 ft. Fine Sand
5a.Well Location:
Sweet Berry Farms 65 � 67 f4 Dark Gray Clay
57 92 Sand
Facility/Owner Name Facility ID#(if applicable)
B s Bridge Rd, Atkinson, NC 28421 92 ft• 10o ft. Gray Clay w/sand streaks
ea
g 100 ft• 106 ft sand
Physical Address,City,and Zip 21.REMARKS
Perkier 106-114 Hard Shale Layers; 114-127 Sand&Clay
County Parcel Identification No.(PIN) 133-141 Sand; 141-162 Sand&Clay
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lit/long is sufficient)
N W � J 3-19-21
Signat6e of Certified Well Contractor Date
6.Is(are)the well(s): l2lPermanent or ❑Temporary By signing this form,I hereby verb that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weft: ❑Yes or ElNo copy ofthis 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: 160 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 50 (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: 8 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
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) 50+ Method of test: Pumping 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013