GW1-2022-01282_Well Construction - GW1_20220127

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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 1-2022-01282
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#:
WS0601455
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
1/5/2022 #8 500
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Sweet Berry Farms Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Bladen 231000229998
Physical Address* Street Address
1824 Moores Swamp Road
Address Line 2
City State/Province/Region
Ivanhoe NC
Postal/Zip Code Country
28447-9497 us
Latitude* 34.5580881000 Long itude*78.2891349000
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
294 surface?
For multiple wells list all depths if different 294
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
4 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 4 cups
14.WATER BEARING/FRACTURE ZONES

From To Description
170 240
in feet in feet
260 290
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
2.00 170.00 8.00 SDR21 PVC
in feet in feet in inches
240.00 260.00 8.00 SDR21 PVC
in feet in feet in inches
290.00 294.00 8.00 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
170.00 240.00 8.00 SDR21 PVC
in feet in feet in inches
260.00 290.00 8.00 SDR21 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 120.00 bentonite pumped
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
120.00 294.00 #3 Gravel poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 15.00 Sand
in feet in feet
15.00 23.00 clay
in feet in feet
23.00 34.00 Sand
in feet in feet
34.00 35.00 Rock
in feet in feet
34.00 45.00 Sand&Clay Layers
in feet in feet

45.00 49.00 Clay
in feet in feet
49.00 60.00 Sand
in feet in feet
60.00 62.00 Silly Clay
in feet in feet
62.00 69.00 Sand
in feet in feet
69.00 89.00 Sand&wood
in feet in feet
89.00 109.00 Sand w/clay layers
in feet in feet
109.00 111.00 Rock
in feet in feet
111.00 117.00 Sand
in feet in feet
117.00 118.00 Rock
in feet in feet
118.00 120.00 Clay
in feet in feet
120.00 121.00 Rock
in feet in feet
121.00 136.00 Clay
in feet in feet
136.00 145.00 Sand
in feet in feet
145.00 146.00 Rock
in feet in feet
146.00 151.00 Sand w/clay layers
in feet in feet
151.00 156.00 Clay
in feet in feet
159.00 169.00 Sand w/clay layers
in feet in feet
169.00 178.00 Clay
in feet in feet
178.00 184.00 Sand w/clay layers
in feet in feet
184.00 187.00 Clay
in feet in feet
187.00 189.00 Sand
in feet in feet
189.00 209.00 Sand&wood w/clay layers
in feet in feet
209.00 249.00 Sand w/clay layers
in feet in feet

249.00 269.00 Sand w/hard clay
in feet in feet
269.00 279.00 Clay
in feet in feet
279.00 294.00 Coarse&Fine Sand
in feet in feet
21. Remarks
169
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