GW1-2021-07225_Well Construction - GW1_20211214

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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#
GW 1-2021-07225
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#:
2021-00028
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
11/24/2021 60
(gallons per minute)"

5.Well Location
Facility/Owner Name*
The Summit of 401 Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland 0407-00-7832
Physical Address* Street Address
Dorado Circle
Address Line 2
city State/Province/Region
Fayetteville NC
Postal/Zip Code Country
28314 US
Latitude* 35.0439364000 Longitude*78.9972087000
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
67 surface?
For multiple wells list all depths if different 67
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
37 12
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)
60 13a.Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:
HTH 1 cup
14.WATER BEARING/FRACTURE ZONES

From To Description
47 64
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 47.00 6.25 SDR21 PVC
in feet in feet in inches
64.00 67.00 6.25 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
47.00 64.00 6.25 SDR21 PVC
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
20.00 67.00 #3 Gravel poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 1.00 Topsoil
in feet in feet
1.00 3.00 Tan Clay
in feet in feet
3.00 8.00 Red Clay
in feet in feet
8.00 25.00 Brown sandy clay
in feet in feet
25.00 30.00 Red&White Sandy Clay
in feet in feet
30.00 40.00 Tan Sand
in feet in feet
40.00 42.00 White Clay
in feet in feet
42.00 45.00 Tan Sand
in feet in feet

45.00 47.00 Gray Clay
in feet in feet
47.00 57.00 Gray Sand
in feet in feet
57.00 60.00 Gray Clay
in feet in feet
60.00 64.00 Gray Sand
in feet in feet
64.00 67.00 Gray 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
........
* 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