WS0801061_GW1_20220217

P,ritEForm �;
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Jonathan Kamionka
Well Contractor Name
3465-A
NC Well Contractor Certification Number
Bill's Well Drilling
Company Name /e /�
2. Well Construction Permit#: IN i U
List all applicable well construction pemdls p.e. UIC. County, Stale, Variance, etc.)
3. Well Use (check well use):
©Municipal/Public
(Heating/Cooling Supply) ©Residential Water Supply (single)
rmmercial []Residential Water Supply (shared)
Recharge
©Groundwater Remediation
Storage and Recovery
[}Salinity Barrier
Test
OStormwater Drainage
ental Technology
[]Subsidence Control
nal (Closed Loop)
[]Tracer
old (Herating/Cooling Rehm)
❑Other (explain under #21 1
4. Date Well(s) Completed: 2/3/2022 Well ID#
so. Well Location:
Johnson Nursery
Facility//lOwner Name Facility ID# (ifapplicable)
Physical Address, City, and Zip
Pende r
County Parcel Identification No. (PM)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field acre Iaulong is sufficient)
N W
6.ls(are) the well(s)O8 Permanent or []Temporary
7. Is this a repair to an existing well: []Yes or E No
IfMis is a repair, fill out known well construction information and explain the nature ofthe
repair under I,21 reniarh' section or on the back ofthis form.
8. For Ceoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: r
9. Total well depth below land surface: 225 (R•)
For multiple wells list oil depths Ifdf rent(erample- 3@200'and2Q100')
10. Static water level below top of casing:
lfwater level Is above caring, Ilse "+'•
11. Borehole diameter: 16
44
(in.)
12. Well construction method: Mud Rotary
(i.e. auger, rotary, cable, & act push, etc.)
For Internal Use Only:
LL WATER ZONES
FROM
To
DESCRIPTION
160 it
22o ft.
ft
I fr.
15. OUTER CASING farmalti-cased wells OR LINER tfa licable
FROM
TO VIAM1IETER THICKNESS MATERIAL
ft.
I ft.
16. INNER
CASING OR TUBING eaMarmed
closed-los
FROM
TO DIAM1tETE0.
THICKNESS
I MATERIAL
+1 It•
160 ft' a in.
SDR17
rx
no ft-
225 It- 1 8 m I
SRD17
PVC
17. SCREEN
FROM I
TO I
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
160 rt
220 rt•
a 1°'
.032
ss
ft
ft.
I.
1&GROUT r
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft
140 ft
Denverite
Pump
140 rt•
150 ft
BanMnits
Pour
ft.
ft.
19. SAND/GRAVEL
PACK
ifa licable
FROM
TO
MATERIAL
EMPLACEMENT METHOD
150 IL
225 IL
#2
Pour
B.
fr.
20. DRILWNG
LOG attaeh
additional sheen ifnecessa
TO
DESCRIPTION oalor, hardness, mNrock e, rain live, etc.)
ft
see atlached
ft.
ft.
ft
PREMARKS
D.
ft
ft.
R.
22. Certification:
Signagife afCertified Well Contractor Date
By signing this fora, I hereby certify that the wells) nuer (were) colearmeted in accordance
wllh l5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conmarclion Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(nJ Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) 300 Method of test: Pump 24c. For Water Supply At Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: s cup completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depadrnent of Environmental Quality - Division of Waver Resources Revised 2.22-2016

BILL'S WELL DRILLING CO.
800 McArthur Road
Fayetteville, North Carolina 28311
Office [phone]
[e-mail] BI s
www.billswelldrilling.com WE
DRI ING
Date: 2/1/2022
Drilling Log Lithology
Johnson Nursery
985 Johnson Nursery Rd, Willard, NC
From
To
Formation Description
0
12
Black & Orange Hard clay
12
20
Fine gray sand
20
30
gray sand and clay layers silty
30
36
clay
36
36
Shells hard spot
37
57
hard dark gray clay small layers of sand
57
97
Black hard clay small layers of sandstone
97
107
Gray clay
107
117
Rock & sand Layers
117
120
Sand & sea shells
120
138
Dark Gray clay and sea shells small streaks of sand
138
140
Fine Gray Sand w/clay
140
141
rock
141
146
Gray clay
146
148
Fine Gray sand
148
149
Rock
149
156
Find Gray sand
156
157
Rock
157
158
Sand
158
164
Sand and shells
164
165
rock
165
178
Clay & fine fray sand
178
198
Tight fine fray sand w/clay
198
214
shells
214
215
rock
215
239
clay
239
251
Silly gray clay
251
253
Sand layer
253
260
Silty clay
Jonathan Kamionka
3465-A