GW1-2022-05675_Well Construction - GW1_20220617

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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 1-2022-05675
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#:
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
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
6/15/2022 100
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Barnhill Contracting Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Robeson
Physical Address* Street Address
211 Crawford Rd
Address Line 2
City State/Province/Region
Lumberton NC
Postal/Zip Code Country
28358 US
Latitude* 0.0000000000 Longitude*0.0000000000
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
154 surface?
For multiple wells list all depths if different 154
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
40 12
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)
100 13a.Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:
HTH 3 cups
14.WATER BEARING/FRACTURE ZONES

From To Description
109 149
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
2.00 109.00 6.25 SDR21 PVC
in feet in feet in inches
149.00 154.00 6.25 SDR21 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
109.00 149.00 6.25 SDR21 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 46.00 bentonite poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
46.00 154.00 #3 Gravel poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 10.00 Sandy clay
in feet in feet
10.00 38.00 Orange Sand
in feet in feet
38.00 42.00 Orange Clay
in feet in feet
42.00 54.00 Gray Sand
in feet in feet
54.00 59.00 Gray Clay
in feet in feet
59.00 66.00 Gray Sand&Clay
in feet in feet
66.00 81.00 Gray Clay
in feet in feet
81.00 85.00 Sand
in feet in feet

85.00 109.00 Gray Clay
in feet in feet
109.00 126.00 Gray Sand
in feet in feet
126.00 129.00 Gray Clay
in feet in feet
129.00 134.00 Gray Sand
in feet in feet
134.00 137.00 Gray Clay
in feet in feet
137.00 140.00 Sand
in feet in feet
140.00 145.00 Clay
in feet in feet
145.00 151.00 Sand
in feet in feet
151.00 154.00 Clay
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
01?; "
Signature of Certified Well Contractor