GW1-2022-01649_Well Construction - GW1_20220216

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
EnvfronmertmfQua(Iry
Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2022-01649
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#:
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
1/27/2022 Col Co HS 200
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Columbus Co Water District Facility ID#
(Required) (If applicable)
County* Parcel Identification No. (PIN)
Columbus
Physical Address* Street Address
Hwy 701
Address Line 2
City State/Province/Region
Tabor City NC
Postal/Zip Code Country
28463 us
Latitude* 0.0000000000 Longitude*0.0000000000
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
329 surface?
For multiple wells list all depths if different 329
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
63.6 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)
200 13a.Method of test:
If applicable pumping
13b. Disinfection type:* 13b.Amount:
HTH 2 cups
14.WATER BEARING/FRACTURE ZONES

From To Description
201 231
in feet in feet
258 263
in feet in feet
284 324
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 20.00 12.00 sch40 PVC
in feet in feet in inches
1.00 180.00 6.25 SDR21 PVC
in feet in feet in inches
180.00 201.00 6.25 SDR17 PVC
in feet in feet in inches
231.00 258.00 6.25 SDR17 PVC
in feet in feet in inches
263.00 284.00 6.25 SDR17 PVC
in feet in feet in inches
324.00 329.00 6.25 SDR17 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
201.00 231.00 6.25 SDR21 PVC
in feet in feet in inches
258.00 263.00 6.25 SDR21 PVC
in feet in feet in inches
284.00 324.00 6.25 SDR21 PVC
in feet in feet in inches
18.GROUT
................
From To Material Emplacment Method&Amount
0.00 15.00 bentonite poured
in feet in feet
15.00 170.00 bentonite pumped
in feet in feet
170.00 185.00 bentonite poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
185.00 329.00 #2 gravel poured
in feet in feet

20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 10.00 Orange&white clay
in feet in feet
10.00 20.00 Gray sticky clay
in feet in feet
20.00 30.00 Gray Turning to orange clay
in feet in feet
30.00 48.00 Orange fine&Med sand with clay float
in feet in feet
48.00 58.00 Orange&gray clay
in feet in feet
58.00 64.00 Gray Clay
in feet in feet
64.00 67.00 Rock
in feet in feet
67.00 73.00 Gray Clay
in feet in feet
73.00 74.00 Rock
in feet in feet
74.00 87.00 Hard Gray Clay
in feet in feet
87.00 88.00 Rock
in feet in feet
88.00 102.00 Gray Clay
in feet in feet
102.00 104.00 Rock
in feet in feet
104.00 128.00 Gray clay
in feet in feet
128.00 148.00 Gray clay w/small streaks of sand
in feet in feet
148.00 168.00 Gray Clay
in feet in feet
168.00 175.00 Clay
in feet in feet
175.00 178.00 Med&fine sand
in feet in feet
178.00 186.00 Gray Clay
in feet in feet
186.00 189.00 Rock
in feet in feet
189.00 195.00 Clay&rock layers
in feet in feet
195.00 196.00 Rock
in feet in feet

196.00 223.00 Layers of fine sand mostly clay
in feet in feet
223.00 256.00 Clay
in feet in feet
256.00 261.00 Sandy clay
in feet in feet
261.00 265.00 Clay
in feet in feet
265.00 271.00 Sand&clay layers
in feet in feet
271.00 282.00 clay
in feet in feet
282.00 313.00 Sand
in feet in feet
313.00 319.00 Rock
in feet in feet
319.00 322.00 Sand
in feet in feet
322.00 329.00 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
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Signature of Certified Well Contractor