GW1-2022-10794_Well Construction - GW1_20221216

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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 1-2022-10794
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#:
WS0601464
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

12/7/2022 500
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Riddle Farms Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Robeson
Physical Address* Street Address
Buckhorn Rd
Address Line 2
City State/Province/Region
Parkton NC
Postal/Zip Code Country
28371 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: 0
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
135 surface?
For multiple wells list all depths if different 135
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
10 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)
500 13a.Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:*
HTH 1 Ibs

14.WATER BEARING/FRACTURE ZONES
From To Description
46 65
in feet in feet
84 110
in feet in feet
125 130
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
2.00 45.00 8.00 SDR21 PVC
in feet in feet in inches
65.00 84.00 8.00 SDR21 PVC
in feet in feet in inches
110.00 125.00 8.00 SDR21 PVC
in feet in feet in inches
130.00 135.00 8.00 SDR21 PVC
in feet in feet in inches
17.SCREEN
....................................................................
From To Diameter Thickness Material
45.00 65.00 8.00 SDR21 PVC
in feet in feet in inches
84.00 110.00 8.00 SDR21 PVC
in feet in feet in inches
125.00 130.00 8.00 SDR21 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 35.00 bentonite pumped
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
35.00 135.00 #3 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 sandy clay
in feet in feet

10.00 12.00 Gray Clay
in feet in feet
12.00 18.00 White Coarse Sand
in feet in feet
18.00 38.00 White coarse sand turning red near bottom
in feet in feet
38.00 48.00 Gray Clay w/small sand layers
in feet in feet
48.00 58.00 Gray sand w/clay layers
in feet in feet
58.00 78.00 Sand&clay layers
in feet in feet
78.00 84.00 Clay
in feet in feet
84.00 100.00 Sand&clay
in feet in feet
100.00 110.00 Sand
in feet in feet
110.00 125.00 Hard Light Gray Clay w/wood
in feet in feet
125.00 135.00 sand
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