GW1--04458_Well Construction - GW1_20240730

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
„This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 150 ft 215 ft
3465-A 270 ft• 275 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a able)
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. o ft. 20 ft 16 in. .250 steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WS0601476 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1-150ft• 215-23w 8 fti. SDR21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) -- —
270 ft. 275 ft. 8 in. SDR21 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: most TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 150 ft 215 ft 8 in' .030 SDR17 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 230 ft 250 ft 8 1' .030 SDR17 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROU
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lalrrigation 0 It le
Non-Water Supply Well: 20 cement poured
❑Monitoring ❑Recovery 0 ft- 150 ftbentointe pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
150 ft• 275 ft #2 gravel poured
❑Aquifer Test ❑Stormwater Drainage —
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geotherinal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tr. ft. SEE ATTACHED
ft. ft.4.Date Well(s)Completed: 11-21-23 well ID# 12 ft. ft.
5a.Well Location: ft. R. - - '
Blueberry Bay L L C ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
13135 N C Hwy 41, Harrells, NC 28444 ft. ft — rr: - .
Physical Address,City,and Zip U i.. tE,t)
21.REMARKS
Bladen
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient)
N w / 11-21-23
Signs a of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IENo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#2l remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 275 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 15 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
mud rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 750 Method of test: pumping 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 2 cups well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

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BILL'S WELL DRILLING Co.
Drilling Log Lithology 11-21-23
BLUEBERRY BAY Back of Farm - Well 12
13135 N C Hwy 41, Harrells, NC - Bladen C:o.
From To Formation Description
0 30 Coarse Brown sand
30 37 Sand & clay Layers
37 57 Clay whine sand
57 67 black clay
67 72 Coarse sand
72 77 Clay
77 97 Clay/fine sand
97 137 Clay
137 152 clay, sand & shells
152 153 Rock w/shells
153 157 Course sand w/shells
157 167 Coarse sand w/clay
167 177 clay whittle sand
177 187 Med & fine sand
187 197 Med Sandw/rock & clay layers
197 207 Sand w/wood
207 217 Fine Sand w/ clay layers
217 227 Clay w/fine sand
227 237 Fine Sand w/clay & wood
237 247 Fine sand w/cllay
247 268 Med sand
268 275 Clay