GW1-2022-01942_Well Construction - GW1_20220224

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka F WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 180 ft' 200 k'
3465-A 300 ft 320 ft
NC Well Contractor Certification Number 15.OUTER CASING ulaedwesORLICNKENR faGcable
O mDT ESFROM TH
MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closeddoo
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft- 178 ft. 6.25 SDR21 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 25 ft Bentonite Pumped
Non-Water Supply.Well:
k. 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. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets N necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soil/rock tym grain size etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft Orange Clay
4.Date Well(s)Completed: Well ID#
4-12-21 10 ft' 28 f White sand&clay
28 ft- 40 ft. White&Pink Hard Clay
5a.Well Location: 40 ft 60 ft. Dark Gray Hard Clay
FEC Properties LLC 60 ft- 95 ft Mixed Light Gray Clays
Facility/Owner Name Facility ID#(if applicable) 95 ft. 130 ft. Gray&Pink Clay
763 Furr Rd, Vass, NC 28394
130 ft• 1140 ft Coarse Gravel
Physical Address,City,and Zip 21 REMARKS
Moore 140-160 Mixed Clay
County Parcel Identification No.(PIN) 165-420 S a
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
FEB 2 4 202?4-12-21
N W _�—
SignYwre of Certified Well Contractor h.-- it Date
11 1"
6.Is(are)the well(s): ©Permanent or ❑Temporary B signing this form,I hereby certl ''' gi'A9 hell fiT�ry,fle-rc t>lA+?r in accordance
Y 8n g f Y I)F)(9 d3 t,�f i rt b)t
with!SA NCAC OIC.0100 or/SA NCAC 01C.02 hell ConslFt2ri ards and that a
7.Is this a repair to an existing well: ❑Yes or ffINo copy ofthis record has been provided to the svetl owner.
If this is a repair,fill out known well construction information and explain the 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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 420 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdijfereni(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,
If,vater 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
Air& Mud Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Air 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 m 5 Method of test: Blow 24c.For Water Supply&Injection Wells:
(gp ) 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
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013