GW1--04466_Well Construction - GW1_20240730

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 ft. ft.
3465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of applmbic)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING;OR TUBING(geothermal closed-loop)
2307-0021 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 169 ft. 6-1/4 in• SDR21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
169 ft. 209 ft. 6-1/4 in' SDR17 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. e
Non-Water Supply Well: !._ 0 30 bentonite pumped
❑Monitoring Recovery ft. ft.
Injection Well: ��A )�L 3 (('9' ft. ft.
❑Aquifer Recharge ❑GrounOpter Remediation 19.SAND/GRAVEL PACK(if applicable)
❑A Ulfer Storage and Recov ' r-''r ' FROM TO MATERIAL EMPLACEMENT METHOD
q g ar: ISarmity Barrier
ft. ft.
❑Aquifer Test D'f '" ❑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,soiUrock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. sand
6-4-24 5 ft. 10 ft• orange clay
4.Date Well(s)Completed: Well ID# —
10 ft. 39 ft. Sand
Sa.Well Location: 39 ft. 55 ft. Gray clay
Clayton Homes 55 fr. 65 ft. sand
Facility/Owner Name Facility ID#(if applicable) 65 ft. 180 ft. Red&Gray Mixed clay
340 Pine Oak, Cameron, NC 28326 1so ft• 195 tt• sand&Wood
Physical Address,City,and Zip
21.REMARKS
Harnett 195-400 Gray Rock
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W ( �/ 6-4-24
Signal a 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)was(were)constructed in accordance
with 15A NCAC 02C.0/00 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.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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: 400 (ft.) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 137 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5.75 (in.) 24b. For Injection Wells ONLY: In addition to sending the form to the address in
Mud & air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 5 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