GW1-2022-01919_Well Construction - GW1_20220224

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
FROM TO DESCRIPTION
Well Contractor Name 180 ft' 200 f-
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas'ed;wells OR LINER if a 6cable)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eother a]closed-loo
2020-1315 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft- 109 ft. 6-1/4' i" SDR21 PVC
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc)
ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public FL ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 50 ft- Bentonite Poured
Non-Water Supply Well: ft. tL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier
rier ft. TO ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hanimm,soiltmek type,grainsize,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft Orange Sand&Clay
4.Date Well(s)Completed: 5-28-21 Well ID# 8 ft- 28 ft. Tan Sand&Gravel
28 ft- 48 ft. Mixed Clays
5a.Well Location: 48 ft 65 ft. Gray Sand&Wood
H&H Homes Lot 9 65 ft- 100 ft Mixed Clay
Facility/Owner Name Facility ID#(if applicable)
100 ft- 200 ft. Gra & d,�Gk r•-'�-•'
4181 Mc Bryde St, Linden, NC 28356 ft. ft ; r
tip 4. D t' •` .,-�
Physical Address,City,and Zip
21.REMARKS
Cumberland 0563-97-7447 FEB 2 4 HE
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 5-28-21
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify(hot the rvell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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 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 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-1@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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"&5.75" (in) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Mud Rotary 24a above, 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) 30+ Method of test: blowing 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