GW1--04484_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:
Joshua Borror 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 39 ft. 45 ft.
4308-A ft. ft. •
NC Well Contractor Certification Number IS.OUTER CASING(for mahi-cased wells)OR LINER 01*bInl
FROM TO DIAMETER THICKNESS MATERIAL
H
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING.OR TUBING.(geothermaLelosed-loop)
2023-60 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft• 39 ft. 4 in' sch40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): 45 ft• 49 ft. 4 in' sch40 PVC
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 39 ft. 45 ft. 4 'n' .032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 25 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)
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
❑Aquifer Test ❑Stormwater Drainage 25 ft• 49 ft. #2 gravel poured
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if neeeaiiry)
❑Geothermal(Closed Loop) ❑Tracer FROM TO _ DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 14 ft. sand clay
2-16-24 14 ft• 32 ft. tan sand
4.Date Well(s)Completed: Well ID#
32 ft. 35 ft• tan sand &clay layers
5a.Well Location: 35 ft. 45 ft. tan sand
Keshia Locklear 45 ft• 49 ft. gray clay
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
339 McNeill St, Hope Mills, NC 28348 ft. ft
Physical Address,City,and Zip 21.REMARKS , o. ,ii.' ' If i' 'l_
Cumberland 0423-37-7522
County Parcel Identification No.(PIN) J U L 3 0 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i-r' 1
(if well field,one lat/long is sufficient) �f,(�, „L,t;fi,� ' -'w' }t)I
34.952147 N -78.920842 W LLIA,...a________DiNc 'SC-.3
2-16-24
Sign ure 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.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DNo 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#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: 49 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 16 (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: 8 (in.) 24b. For Injection 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: 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) 15 Method of test: bailed 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