GW1-2022-03891_Well Construction - GW1_20220422

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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 1-2022-03891
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#:
2021-216
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
1/14/2022 20
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Christopher Poulk Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland 1408-01-2575
Physical Address* Street Address
2590 Page Road
Address Line 2
City State/Province/Region
Stedman NC
Postal/Zip Code Country
28391 US
Latitude* 35.0732581000 Longitude*78.6662939000
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
340 surface?
For multiple wells list all depths if different 228
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
92 5.75
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)
20 13a. Method of test:
If applicable blow
13b. Disinfection type:* 13b.Amount:
HTH 1 cup
14.WATER BEARING/FRACTURE ZONES

From To Description
280 340
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 228.00 6.00 .188 Steel
in feet in feet in inches
17.SCREEN
.................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
.......................................................
From To Material Emplacment Method&Amount
0.00 20.00 bentonite poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 10.00 Black Clay
in feet in feet
10.00 20.00 Coarse Sandy Gravel
in feet in feet
20.00 220.00 Mixed Clay
in feet in feet
220.00 224.00 Soft Rock
in feet in feet
224.00 228.00 Hard Green Rock
in feet in feet
228.00 280.00 Green&Dark gray rock
in feet in feet
280.00 340.00 Light Gray Rock
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
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Signature of Certified Well Contractor