GW1--04486_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 50 ft. 56 ft-
3465A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap ble)
FROM TO DIAMETER THICKNESS Il MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2023-00565 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft' 50 ft. 4 t°' sch40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
56 ft- 60 ft• 4 1n. sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 50 k 56 ft' 4 1°' .0320 sch40 PVC
ft. ft. in.(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 28 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
28 ft- 60 ft. #2 gravel poured
❑Aquifer Test ❑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,soil/rock type,grain sae,elc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. brown sand
3-1-24 15 ft. 27 ft- black clay&wood
4.Date Well(s)Completed: Well ID#
27 ft. 42 ft. brown sand
5a.Well Location: 42 ft• 48 ft. black clay
America's Home Place
Facility/Owner Name Facility ID#(if applicable) 48 ft. 56 ft. gray sand
56 ft- 60 ft. Light gray clay
3752 McKinnon Rd, Fayetteville, NC 28312 ft. ft. ... -
Physical Address,City,and Zip 21.REMARKS +ti ,r l 1 v p;;,
Cumberland 0473-31-5549 JULounty Parcel Identification No.(PIN) 'J 3 0 1024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Irdo:,;,a,i-.1 i-
(if well field,one lat/long is sufficient) ` �''Str@!
3-1-24 N �,
Signal a of Certified ell Contractor Date
6.Is(are)the well(s): ElPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No 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: 60 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing 15 (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)_1.5 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