GW1--04495_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 Kamonka 14.WATER ZONES
FROM TO _ DESCRIPTION
Well Contractor Name 45 ft. 57 ft.
3465-A 62 ft. 70 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.INNER CASING OR TUBING(geothermal dosed-loop)
2024-00691 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1 ft 45 ft. 4 1n. sch40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) -
52-62 ft• 70-74 ft. 4 1°' sch40 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 45 ft. 57 ft- 4 1°' .032 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 62 ft. 70 ft. 4 1n. .032 sch40 PVC
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
BIrrigation 0 ft- 25 ft. bentonite poured
Non-Water Supply Well: ft tt -
❑Monitoring ❑Recovery -
Injection Well: ft. ft.
['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 25 ft. 74 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 size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 ft. Sandy Clay
6-24-24 14 ft. 29 ft. Sand&Clay Layers
4.Date Well(s)Completed: Well ID# 29 ft. 33 ft. Black Clay
5a.Well Location:
Element Construction 33 ft. 57 ft. Tan sand (float)
57 ft. 62 ft• Clay
Facility/Owner Name Facility iD/I(if applicable)
62 IL 70 ft. Tan sand
1 11 1 Annondale Way, Fayetteville, NC 28303
70 tt' 74 ft. Clay
Physical Address,City,and Zip
21.REMARKS
Cumberland • f'- �
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: UL 3 0 2024
22.Certification:
(if well field,one lat/long is sufficient) _
_1 ltk
N W Irrto;>~ai'[MAW; '1
Si a of Certified ell Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo 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 121 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: 74 (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@100') construction to the following:
10.Static water level below top of casing 38 (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
pumped 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 40 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