GW1-2021-02115_Well Construction - GW1_20211012

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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 1-2021-02115
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#:
2020-1400
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* C Injection Well C Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) C Industrial/Commercial
r Irrigation C Municipal/Public/Community
r Residential Water Supply(single) C Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/28/2021 Lot 15 20
(gallons per minute)"

5.Well Location
Facility/Owner Name
H&H Homes Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland 0563-08-1212
Physical Address* Street Address
4253 McBryde Road
Address Line 2
City State/Pro\ince/Region
Linden NC
Postal/ZZp Code Country
28356 us
Latitude* 35.2294570000 Longitude*-78.7649598000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* f Yes r No
If this is a repair,fill out known well construction information and a)plain 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
240 surface?
For multiple wells list all depths if different 108
(e)ample-3@200'and 2@1001 in feet
11. Borehole diameter:
10.Static water level below top of casing:(ft.) 5.75
If water Iewl is abo\e casing,use"+" in inches
12.Well construction method:
C Auger r Air Rotary r Cable Tool
C Direct Push r Mud Rotary r Rotosonic
C Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
20 13a. Method of test:
If applicable blow
13b. Disinfection type:* 13b.Amount:*
HTH 1 cup
14.WATER BEARING/FRACTURE ZONES

From To Description
110 120
in feet in feet
180 240
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 108.00 6.25 SDR21
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 25.00 Bentonite poured
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 10.00 Orange Sandy Clay
in feet in feet
10.00 25.00 Tan Sand&Gravel
in feet in feet
25.00 84.00 Gray Clay
in feet in feet
84.00 93.00 Gray Sand
in feet in feet
93.00 108.00 Rock
in feet in feet
108.00 240.00 Gray Rock
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
...............................................................................................................................................................
*rJ 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'�a� " MeA.
Signature of Certified Well Contractor
Submittal Date 10/12/2021