GW1--04548_Well Construction - GW1_20240731

W LLL CUINJ I KU C I'ION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonatahn Kamionka 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 140 ft. 160 ft.
3465-A ft. ft.
NC Well Contractor Certification Number 1S.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)
204519 FROM TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: +1 ft' 128 ft. 6-1/8 in. SDR21
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) PVC
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
®Irrigation 0
Non-Water Supply Well: ft' 20 ft. Bentorlite pumped
❑Monitoring ❑Recove ry 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
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. 12 ft. Mixed Clay
4.Date Well(s)Completed: 4-4-24 Well ID# 12 ft. 40 ft. Coarse Tan Sand&Gravel
40 ft. 70 ft. Black&Red Clay
5a.Well Location:
Curl Properties LLC 70 ft. 240 ft Soft Gray Rock
ft. ft.
Facility/Owner Name Facility ID#(if applicable) __ y i -
ft. ft. •
88 Amit Dr Princeton, NC 27569
ft. ft.
Physical Address,City,and Zip 21.REMARKS ,) i t. .
Johnston
,.- ,rti.: ; ':
County Parcel Identification No.(PIN) Ii f.G;:•+t""
D'A 1'.vi
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 4-4-24
Signal o Certified Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with l5A 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 E No 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: 240 (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: (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 Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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: blow 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
I3b.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