GW1-2021-06499_Well Construction - GW1_20211208

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2021-06499
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Jonathan Kamionka [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
Owner 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#:
2020-1316
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well (includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
11/29/2021 40
(gallons per minute)"

5.Well Location
Facility/Owner Name* Facility ID#
H&H Homes Lot 16
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland 0573-08-0150
Physical Address* Street Address
4265 McBryde Road
Address Line 2
city State/Province/Region
Linden NC
Postal/Zip Code Country
28356 us
Latitude* 35.2298064000 Longitude*78.7647547000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes 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
220 surface?
For multiple wells list all depths if different 116
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 5.75
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
40 13a. Method of test:
If applicable blow
13b. Disinfection type:* 13b.Amount:
HTH 1 cup
14.WATER BEARING/FRACTURE ZONES

From To Description
160 200
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 116.00 in inches
in feet in feet
17.SCREEN
.................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
.......................................................
From To Material Emplacment Method&Amount
0.00 20.00 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 11.00 Sandy clay
in feet in feet
11.00 23.00 Sand&Gravel
in feet in feet
23.00 55.00 Gray Sandy Clay
in feet in feet
55.00 65.00 Gray&Red Sandy Clay
in feet in feet
65.00 71.00 Brown Clay
in feet in feet
71.00 77.00 Gray Clay
in feet in feet
77.00 83.00 Sand
in feet in feet
83.00 87.00 Sand&Gravel
in feet in feet
87.00 96.00 Sand&Clay
in feet in feet
96.00 108.00 Soft Rock
in feet in feet

108.00 116.00 Gray Rock
in feet in feet
116.00 220.00 Gray&Red 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
.......................................................................................................................................................................................
* 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
Signature of Certified Well Contractor