GW1-2022-01932_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 It. 240 ft
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'(for multi cased wells OR LINER if a livable
I31IIrS Well Drilling CO. FROM ft. To ft. DIAMETER na THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING eother at closed-looril
2020-1364 FROM TO DIAMETER I TTHICKNESSI MATERIAL
2.Well Construction Permit#: +1 It. 125 rt• 6-1/8 1O
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) SDR21 PVC
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
EFROMTO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 50 fL bentonite poured
Non-Water Supply Well: ft.
❑Monitoring ❑Recovery
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity FROM Barrier ft. TO ft. MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain siu,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft. 10 ft. Orange Clay
4.Date Well(s)Completed:
6-15-21 Well ID# 10 It- 30 ft. Orange Sand&Gravel
30 fr. 50 ft. Orange Clay
Benjamin Stout Stout Real Estate Services,Inc.Well : 50 ft. 65 ft. Orange,Tan,Gray Sand
B
Facility/Owner Name Facility ID#(ifapplicable) 65 ft 110 ft. Mixed Clays
9066 Hawkins Rd, Linden, NC 28356 110 ft. 240 ft. Gray&Red Rock
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Cumberland 0573-16-2661 - _-..-
County Parcel Identification No.(PIN) 202?
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
irk 1t�i , :a PrV M
N W .r.VIC
Signat of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)nvas(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 EINo copy of this record has been provided to the well owner.
1f Ihis is a repair,fill out known well construction information and explain Ille nature of the
repair under#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 Ille same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 240 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use^+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"&5.75" (in) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Air& 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) 30 Method of test: blow
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