GW1--04493_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 470 ft- 480 ft•
3465-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-64 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 228 f• 6 in. .188 steel
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 . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply ft. ft. in.
( � g PP Y) pp y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM j TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 25 ft• bentonite pumped
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicably
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additionalsbeets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 10 ft. Sandy clay
5-9-24 10 ft- 18 ft• Gravel
4.Date Well(s)Completed: Well ID# 18 ft' 200 ft• mixed clay
5a.Well Location: 200 ft• 220 ft• Soft Green Rock
Christyphi Construction
Facility/Owner Name Facility ID#(if applicable) 220 ft' 480 ft• Black&Gray Rock
ft. ft.
1924 Ardor Ave, Fayetteville, NC 28306 e. ft.
Physical Address,City,and Zip 21.REMARKS I *+.... '-''k. . .r 1,...'Sk^="
Cumberland 0454-83-2222
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 0 , " ={. -`> Je`
22.Ce,'ficati i n:
(if well field,one lat/long is sufficient) /
N W / 5-9-24
Si:Si:,' -•of Certified ell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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
S.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: 480 (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: (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
Med & 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) 10 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