GW1-2022-01920_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 200 ft' 260 ft
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 'Gcable
BIIItS Well Drilling CO. FROM ft TO ft.
t DIAMETER m THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eothermal closed-loo`
2020-1317 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 129 11• 6-1/4' SDR21 PVC
List all applicable well permits(i.e.County,State,Variance,h jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSUE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(sm(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h anon 0 ft. 50 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
ft. ft. MATERIAL I EMPLACEMENT METHOD
❑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,soittrock tyM Krain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. g ft. Orange Sandy Clay
4.Date Well(s)Completed: 5-26-21 Well ID# 8 ft. 28 ft. Tan Sand&Gravel
28 ft. 45 ft Gray Clay
5a.Well Location: 45 ft. 60 ft Gray Sand
H&H Homes Lot 10
Facility/Owner Name Facility ID#(ifapplicable) 60 ft. ft Gray Clay
4191 Mc B de St, Lind NC 28356 95 f'• 10o ft. Gray Sand
ry en, 100 ft- 260 ft. G fttlak
Physical Address,City,and Zip 21.REMARKS
Cumberland 0563-97-7586
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) •`�¢• "m^"
/ IT-.4� '��'�Irl�.la I`r,`r,*11 ;�
N W // '5-213=21
Sigma of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑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 1:21 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: 260 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2(a3100') construction to the following:
10.Static water level below top of casing: (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" &5.75" (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) 20+ 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water:Resources Revised August 2013