GW1-2022-10083_Well Construction - GW1_20221115

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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#
GW1-2022-10083
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#:
39581
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

11/10/2022 20
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Steven&Penny Stout Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Moore 0044723
Physical Address* Street Address
1301 Cypress Church Road
Address Line 2
City State/Province/Region
Cameron NC
Postal/Zip Code Country
28326-7235 US
Latitude* 35.2458709000 Longitude*-79.1771888000
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
220 surface?
For multiple wells list all depths if different 158
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
80 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
190 220
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 158.00 6.25 SDR21 PVC
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 30.00 bentonite PC
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 Tan Sandy clay
in feet in feet
10.00 110.00 Gray&Red mixed clays
in feet in feet
110.00 125.00 Sand
in feet in feet
125.00 145.00 Gravel
in feet in feet
145.00 158.00 Gray Rock
in feet in feet
158.00 220.00 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