GW1-2022-01926_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 FR WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 38 fL 44 &
3465-A h. &
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. fr. 1 ft. I in.
Company Name 16.INNER CASING OR TUBING eothermaI closed-loop)
2020-1159 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 "' 44 ft. 4 1°• sch40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
44 ft' 48 ft' 4 in. sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 38 fL 44 ft. 4 1n. .032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single) ft. ft. in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 24 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 EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
24 48 #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,soit/rock tyM grain size,ete
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft Topsoil
2-3-21 1 ft. 5 ft. Sand&Clay
4.Date Well(s)Completed: Well ID# 5 ft• 11 fr. Orange Clay
5a.Well Location: 11 It. 48 ft. Sand
Caviness Land Lot 9 rt. ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft
1419 Creekwood Rd, Hope Mills, NC 28348 ft. ft
Physical Address,City,and Zip 21.REMARKS
Cumberland 0421-32-9654
County Parcel Identification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: � � t vg,
(if well field,one IaUlong is sufficient) 2iPii to r w 54 11.'� g I
t'"Y .A.. uft
N W
Signatu 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),vas(were)constructed in accordance
with 1 SA 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 9lNo copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 911 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: 48 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdii erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12 Division of Water Resources,Information Processing Unit,
If,vater 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 Rota 24a above, 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) 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013