GW1--04586_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 100 ft 140 ft. 16 gpm
3465-A 140 it• 200 ft. 15 gpm
NC Well Contractor Certification Number IS OUTER CASING(for multi-cased wells)OR LINER(if Me)
FROM TO DIAMETER THICKNESS If MATERIAL
Bill's Well Drilling Co. ft. ft. in. .
Company Name It INNER CASING OR TUBING(geothermal clued-loop)
143406 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +2 ft 88 ft 6-1/4 i°' SDR21 PVC
List all applicable well permits(i.e.County,Slate,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 ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 10 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
mIrrigation 0 ft• 20 ft bentonite pumped
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 14.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sins,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 12 ft Mixed clay
4.Date Well(s)Completed: 12-28-23 Well ID# 12 ft 26 ft Sand
26 ft. 66 ft. Mixed Clays
5a.Well Location: 66 ft• 80 ft. Green rock
Matt Frazier 80 ft 200 ft Gray Rock
Facility/Owner Name Facility ID#(if applicable) ft. ft. . ..
7710 Elevation Rd, Benson, NC 27504 ft. ft. • ,ram~
Physical Address,City,and Zip 21.REMARKS �t i'1 I{
Johnston V
County Parcel Identification No.(PIN) ,#,'.. : 't.:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Ce fication:
(if well field,one lat/long is sufficient)
N W 12-28-23
Si of Certified We 1 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 I SA 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 EINo 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 421 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: 200 (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: (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
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
blow 24e.For Water Supply&Injection Wells:
13a.Yield(gpm) 30 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