GW1-2022-01923_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 35 ft. 41 ft.
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for molti�ased wens ORLIIVER if a Gcable
FROM TO DIAMETER THICIWESS MATERIAL
Bill's Well Drilling Co. ft. & in
Company Name 16:INNER CASING OR TUBING: eothermal'dosed-loo -
2021-229 FROM TO DIAMETER I THICIINESS MATERIAL
2.Well Construction Permit#: +1 ft' 35 ft- 4 1°' SCh40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
41 1" 45 ft' 4 in' SCh40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 "' 41 ft' 4 in. .032 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT %FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20 ft. bentonite poured
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a"lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 ft. 45 ft. #3 Gravel Poured
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.=DRILLING:LOG attach additional sheets ifnecessa°'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain sin,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Orange Sandy Clay
5-14-21 5 It. 45 ft Tan&White Sand
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Caviness Land Lot 40 ft. ft.
Facility/Owner Name Facility lD#(if applicable)
ft. ft
1520 Creekwood Rd, Hope Mills, NC 28348
ft. ft
Physical Address,City,and Zip S _ -
21:REMARKS"
Cumberland 0421-13-3521 9
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one latflong is sufficient)
N W
Signatyfe of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the we//(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 well: ❑Yes or ElNo copy ofthis record has been provided to lite 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: 45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(example-3Q200'and 1@100') construction to the following:
10.Static water level below top of casing: 17 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b. For Iniection Wells ONLY;: In addition to sending the form to the address in
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.)
DIVIs10n of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15-20 Method of test: balled 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.
Fort GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013