GW1--04478_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 290 ft. 380 ft.
3465-A 380 ft. 420 ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased walla)OR LINER(if a bte) -
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermaLdosed400p)
2023-177 FROM TO DIAMETER THICKNESS MATERIAL
—
2.Well Construction Permit#: +1 ft. 274 ft- 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 ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1$.
FROMGROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 40 ft. bentonite pumped
Non-Water Supply Well: ft. ft.
❑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 ft ft.
❑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. 4 ft. topsoil
5-23-24 4 ft. 30 ft. gray sand
4.Date Well(s)Completed: Well ID# 30 ft. 90 rt. clay
5a.Well Location: 90 ft• 100 ft' sand
Thomas Miles
Facility/Owner Name Facility ID#(if applicable) 100 ft' 200 ft' mixed clay
200 ft• 260 ft. red weathered rock
2156 John Hall Rd, Fayetteville, NC 28312 260 rt. 420 ft• gray rock
Physical Address,City,and Zip
21.REMARKS
Cumberland 0474-38-3243
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: J U L 3 0 2024
22.Certification:
(if well field,one lat/long is sufficient)
/ ,-,'20,;i -; i-- 3-24
N W ` :C434
Sign a of Certified Well 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 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 DNo 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: 420 (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: 142 (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 Iniection Wells ONLY: In addition to sending the form to the address in
Mud & 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) 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