GW1--04494_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 40 ft. 46 ft.
3465-A 54 ft• 60 ft•
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNERCASING OR TUBING(geothermal closed-loop)
2022-00368 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft. 40 ft• 4 1n. sch40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): 46-54 ft. 60-64 ft• 4 1n. sch40 PVC
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 40 ft' 46 ft• 4 1°' .032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) 54 ft. 60 ft• 4 1n' .032 sch40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 21 ft• bentonite poured
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft.
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 21 ft. 64 ft. #2 gravel poured
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,gain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 10 ft. Mixed clay
4-15-24 10 ft' 22 ft. Gray sand
4.Date Well(s)Completed: Well ID# 22 ft. 40 ft. gray clay
5a.Well Location: 40 ft• 45 ft' Gray sand&clay layers
Stacy & Becki Bolton 45 ft• 54 ft• Gray Clay
Facility/Owner Name Facility 1D#(if applicable) 54 ft. 60 ft. Coarse gray sand
787 Wade-Stedman Rd, Stedman. NC 60 u. 64 ft. Gray Clay
Physical Address,City,and Zip
21.REMARKS .... <5
Cumberland 0496-17-2403 • °•
County Parcel Identification No.(PIN) +�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: J IJ 3 o (��¢
(if well field,one lat/long is sufficient) 22.Certifies n:
N W 154-:#.; y
Si tore of Certified Well Contractor Date
6.Is(are)the well(s): ZPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 5A 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 EfiNo 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: 64 (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: 9 (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 Infection 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
17 pumped 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) _ Method of test:
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