GW1-2022-05690_Well Construction - GW1_20220617

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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 1-2022-05690
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#:
Ws0801068
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
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

6/5/2022 300
(gallons per minute)"
5.Well Location
Facility/Owner Name* Facility ID#
Sweet Berry Farms 6
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Pender 2239-12-1428-0000
Physical Address* Street Address
Beatty Bridge Rd
Address Line 2
City State/Province/Region
Atkinson NC
Postal/Zip Code Country
28421 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
295 surface?
For multiple wells list all depths if different 295
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
80 15
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)
300 13a.Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:*
HTH 4 cups

14.WATER BEARING/FRACTURE ZONES
From To Description
150 210
in feet in feet
245 285
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
2.00 150.00 8.00 SDR21 PVC
in feet in feet in inches
210.00 245.00 8.00 SDR21 PVC
in feet in feet in inches
285.00 295.00 8.00 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
150.00 210.00 8.00 SDR21 PVC
in feet in feet in inches
245.00 285.00 8.00 SDR21 PVC
in feet in feet in inches
18.GROUT
.......................................................................................................
From To Material Emplacment Method&Amount
0.00 130.00 bentonite pumped
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
130.00 295.00 #2 gravel poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 20.00 Sand
in feet in feet
20.00 40.00 Sand&Clay
in feet in feet
40.00 50.00 Sand
in feet in feet
50.00 75.00 Black Clay
in feet in feet

75.00 88.00 sand
in feet in feet
88.00 95.00 Clay
in feet in feet
95.00 96.00 Rock
in feet in feet
96.00 109.00 Sand&Clay Layers
in feet in feet
109.00 150.00 Rock layers&sand
in feet in feet
150.00 169.00 Sand
in feet in feet
169.00 189.00 Sand w/some clay
in feet in feet
189.00 209.00 Fine Sand
in feet in feet
209.00 229.00 Sand w/some clay
in feet in feet
229.00 237.00 Rock
in feet in feet
237.00 249.00 Rock layer&clay
in feet in feet
249.00 289.00 Sand
in feet in feet
289.00 295.00 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
01&- "�1e�sZ2
Signature of Certified Well Contractor