GW1-2021-01720_Well Construction - GW1_20210429

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
e®� FROM TO DESCRIPTION
Well Contractor Name 52-62 ft' 73-78 ft'
3465-A SG
% 9 95 ft 105 ft.
NC Well Contractor Certification Number �� .OUTER,CASING for m°lti-cased*eft OR LINER if a cable)
Bill's Well Drilling Co. P ��ptoceso�9 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING°(geothermal closed-loo
WS06-01439 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: +2-52 ft' 62-73 ft- 6-1/4 1° SDR21 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
78 ft• 95 ft• 6-1/4 1°' SDR21 PVC
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 52-62ft. 73-78 ft' 6-1/4 1n' .040 SDR21 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 95 ft' 105 ft- 6-1/4 1n- .040 SDR21 PVC
[ZIndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 50 ft- Bentonite Pumped
Non-Water Supply Well:
k. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if so ticable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft•
❑Aquifer Test ❑Stormwater Drainage 50 ft- 110 #3 Gravel Poured
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiVrock type,gnin s¢q etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. See Attached
ft. ft.
4.Date Well 11-24-2020 s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Hoke Healthcare, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. Et.
210 Medical Pavillion Dr, Raeford, NC 28376 ft. ft.
Physical Address,City,and Zip 21 REMARKS
Hoke 494660201463
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 N 11-24-2020
Sign re of Certified Well Contractor Date
6.Is(are)the well(s): IaPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO 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#21 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: 110 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12 (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: 12 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Mud Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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
(gp ) 24c.For Water Supply&Injection Wells
m :
13a.Yield 40 Method of test: Pumped
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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

BILL'S WELL DRILLING CO.
800 McArthur Road
Fayetteville,North Carolina 28311
Office [phone] _
[e-mail] BILING
`
www.biUsweildriUing.com WE
DRI
Date: 11/24/2020
Drilling Log Lithology
Hoke Healthcare, LLC
210 Medical Pavillion Dr, Raeford, NC 28376
Hoke Co
From To Formation Description
0 11 Mixed Clay
11 18 White Sand &Gravel
18 28 Fine White Sand (Float)
28 38 Tan Sand w/clay layers (Float)
38 50 Tan Sand w/clay layers
50 51 Red Clay
51 58 Tan Sand
58 65 Mixed clay w/small layers sand
65 66 Light Gray Clay(Sea Shells)
66 74 Gray Clay
74 77 Medium Sand
77 95 Gray Clay
95 101 Medium Sand
101 107 Sand (Tight)
107 110 Dark Gray Clay
Jonathan Kamionka
3465-A