GW1-2022-01929_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 Kamlonka 14.WATER ZONES'FROM TO DESCR PTION
Well Contractor Name 240 IL 260 "'
3465-A ft. ft,
NC Well Contractor Certification Number 15.,OUTER
FROM CAOS ING- om wWb ORIN s leable uDIAM '
MATERIAL
Bill's Well Drilling Co. e. ft in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
2020-1398 FROM TO DIAMETER TIUCKNE5S MATERIAL
1.Well Construction Permit#: +1 ft. 105 rt. 6-1/4 in. SDR21 PVC
List all applicable well permits fl.e.County.State,Variance,Injection,etc.)
+1 ft. 113 ft 4 sch40 PVC
3.Well Use(check well use): 17.SCREEN .
. - d.
Water Supply Well: FROM TO DIAMETER SLOTSUE THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic ft ft in
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENr METHOD&AMOUNT
❑Irri ation 0 rt. 20 ft. bentonife poured
Non-Water Supply Well:
❑Monitoring ❑Recovery
0 ft 113 ft. bentonite poured
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.`SANDIGRAVELPACK da liestile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG aftaih additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer E27 "
TO DESCRIPTION colar,hardrress,scillrack rain ' etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks ft. 9 ft Red Sand Clay
4.Date Well(s)Completed: 5-29-21 well ID# 27 ft. Tan Sand&Large Gravel
60 ft, Mixed Clays
5a.Well Location:H&H Homes Lot 11 60 70 ft Gray Sand
70 ft• 90 ft• Mixed Clay
Facility/Owner Name Facility ID#(if applicable) 90 ft• 105 ft. �•� ft "�
4201 Mc Bryde St, Linden, NC 28356 ft -
Physical Address City,and Zip 21.REMARKS
Cumberland 0563-97-8624 -
County Parcel Identification No.(PIN) P a-'�'^
Wt I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:ffi {
(if well field,one lat/long is sufficient)
�i'r/../
N W 5-29-21
Signatu a of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wall(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Constritction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of This record has been provided to ilia well owner.
If llds Is a repair,fill out known well construction information and explain the mature of ilia
repair under 421 remarks section or on Ilia back of this farm. 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 ityection 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 wclis list all deptis iftli ferent(example-3@200'and 2@1001 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 (in.) 24b. For Infection 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.WeO construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,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.
I
Fomi GW-I North Carolina Department of Environment and Natural Resources—Division of Watcr,Resourees Revised August 2013