GW1-2022-07438_Well Construction - GW1_20220819

w
®,
NORTH CAROLINA
ilk
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 1-2022-07438
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#:
33237
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

8/18/2022 10
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Mildred Smith Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Moore 20080028
Physical Address* Street Address
5828 Beulah Hill Church Road
Address Line 2
City State/Province/Region
West End NC
Postal/Zip Code Country
27376-9157 US
Latitude* 35.2649008000 Long itude*-79.5135545000
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
94 surface?
For multiple wells list all depths if different 94
(example-3@200'and 2@100') in feet
11.Borehole diameter:
10.Static water level below top of casing: (ft.) 8
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)
10 13a.Method of test:
If applicable pumped
13b. Disinfection type:* 13b.Amount:*
HTH 1 cup

14.WATER BEARING/FRACTURE ZONES
From To Description
60 65
in feet in feet
84 90
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 60.00 4.00 sch40 PVC
in feet in feet in inches
65.00 84.00 4.00 sch40 PVC
in feet in feet in inches
90.00 94.00 4.00 sch40 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
60.00 65.00 4.00 sch40 PVC
in feet in feet in inches
84.00 90.00 4.00 sch40 PVC
in feet in feet in inches
18.GROUT
.......................................................................................................
From To Material Emplacment Method&Amount
0.00 35.00 bentonite poured
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
35.00 94.00 #3 Gravel poured
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 8.00 Sand
in feet in feet
8.00 16.00 Orange Sand&Clay
in feet in feet
16.00 20.00 Orange&White Clay
in feet in feet
20.00 30.00 Orange Clay w/sand streaks
in feet in feet

30.00 44.00 Coarse sand
in feet in feet
44.00 48.00 Sandy clay
in feet in feet
48.00 58.00 Sand
in feet in feet
52.00 60.00 Clay
in feet in feet
60.00 65.00 Sand
in feet in feet
65.00 84.00 Gray&Tan Clay
in feet in feet
84.00 90.00 Sand
in feet in feet
90.00 94.00 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
ogr'I64"OA�"&
Signature of Certified Well Contractor