GW1--04508_Well Construction - GW1_20240730

W ELL L.lin 1 ItUl.,1 lV111 itrA,UKU 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 30 ft. 88 ft.
3465-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(1f 'hie)
FROM TO DIAMETER THICKNESS I MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 561 +1 ft' 78 ft. 4 1°' sch40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) —
84 ft. 88 ft. 4 1n' sch40 PVC
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 78 ft. 84 ft. 4 "'' 032 sch40 PVC
ft. ft. in.❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well:—, .' ', }�^•'"' 20 bentonite poured
['Monitoring - - a Y CTfte ove ft. ft.
ry
Injection Well: 4 ft. ft.
❑Aquifer Recharge JUL 0 �O?❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Retkoyery'; ;a-r 5kDNttiet Barr
ier
tn ft. ft.
20 88 #2 gravel poured
[Aquifer Test D'i:'^w S''-'40❑Stormwater Drainage
ft. ft.
['Experimental Technology OSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO RILLING�(Minh DPT
DESCRIPTION
lo,,hardness,soiUrock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Orange Sand
11-29-23 5 ft" 28 ft. Red&White Clay
4.Date Well(s)Completed: Well ID#
28 ft. 40 ft. Tan Sand
sa.Well Location: 40 ft. 50 ft' Yellow Clay
Kevin Watts 50 ft. 88 ft. Tan sand
Facility/Owner Name Facility lD#(if applicable) ft. ft.
433 Old Forest Rd, Raeford, NC 28376 ft. ft.
Physical Address,City,and Zip Zl.REMARKS
Hoke 494440001013
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 11-29-23
Signs a of Certified Well Contractor Date
6.IS(are)the well(s): 12IPermenent or ❑Temporary By signing this form,1 hereby certifir 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 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
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: 88 (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: 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
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