GW1-2021-01228_Well Construction - GW1_20210903

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
G W 1-2021-01228
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Jonathan Kamionnka [e-mail]
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
..................................................................................................................................................................................................................... ...................... ....................... ....................... ................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
3465 A JONATHAN KAMIONKA BILLS WELL DRILLING CO, INC.
2.Well Construction Permit#:
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply WeII* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
8/24/2021 10
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Carolina Concrete Finishing, Inc. Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Hoke
Physical Address* Street Address
570 Hobson Road
Address Line 2
City State/Province/Region
Raeford NC
Postal/ZZp Code Country
28376 us
Latitude* 35.0331069000 Longitude*79.1437255000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* F Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
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.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
70 surface?
Formultplewells Iistall depths if different 1
(e)ample-3@200'and 2@100') in feet
11. Borehole diameter:
10.Static water level below top of casing:(ft.) 12
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
10 13a. Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:*
HTH 1 cup
14.WATER BEARING/FRACTURE ZONES

From To Description
46 66
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 46.00 6.25 SDR21 PVC
in feet in feet in inches
66.00 70.00 6.25 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
46.00 66.00 6.25 .030 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 40.00 Bentonite Pumped
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
40.00 70.00 #3 gravel poured
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 8.00 Tan Sand
in feet in feet
8.00 15.00 Tan Sandy Clay
in feet in feet
15.00 23.00 Mixed Clay
in feet in feet
23.00 35.00 Clay&Sand Layers
in feet in feet
35.00 38.00 Mixed Clay
in feet in feet
38.00 66.00 White Coarse Sand
in feet in feet
66.00 70.00 Mixed Clay
in feet in feet
21.Remarks

22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
......... ...... ...... ..... .....
*N7 By signing this form, I hereby certify 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 copy of this record has been provided to
the well owner.
23.Certification*
C'��rtt/rrrar. �rta>rr��T?.
Signature of Certified Well Contractor
Submittal Date 9/3/2021