GW1--04504_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka t4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 105 ft 195 ft.
3465-A ft. ft.
.1 FROM
OU17 CG lit` 'w'idld)OR LW*i f pglk ibk)NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS 11 MATERIAL
Bill's Well Drilling Co. ft ft. in.
Company Name 16.INNERCASINGOR TURING elosid-10•18
WS0601480 FROM TO DIAMETER THICKNESSMATERIAL
2.Well Construction Permit#: M+1 tr. 105 ft. 6-1/4 is SDR21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use): 195 ft' 198 ft 6-1/4 in* SDR17 PVC
1! i
Water Supply Well: FROM TO • DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 105 M' 195 it. 6-1/4 in* .032 SDR21 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
®Irrigation 0 ft. 80 ft bentonite pumped
-
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundw'ater Remediation 19.SAND/GRAVEL P4CK(lfapplkabie).
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier 80 ft• 198 ft. #2 gravel tremied
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(att.ch.4d be at,if aace.i.ry
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnet,soil/rock type,train tine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. SEE ATTACHED
1-3-24 ft. ft.
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft. ``
Blue River Legacy Farms ft. ft. JUL ;i 0 2024
Facility/Owner Name Facility lD#(if applicable) ft. ft.1289 Barnes Blueberry Rd, Elizabethtown, NC 28337 ft ft If«=•-.,tear.'e-r','•',,2 UPI
Physical Address,City,and Zip 21.REMARKS
Bladen 134300573353
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W
1-3-24
Signal of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certi&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC(12C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copy of this record has been provided to the well owner.
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. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 198 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Stalk water level below top of casing: 33 (p,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"," 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 12 (in.) 24b. For Iniection Wells ONLY: hi addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
Mud rotary
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
300 pumped 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 2 cups well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

BILL'S WELL DRILLING CO.
800 McArthur Road414
Fayetteville, North Carolina 28311 BI S
Office [phone] E
[e-mail] RI IG
N
www.billswelldrilling.com
Date: 1/3/2024
Drilling Log Lithology
Blue River Legacy Farms
1289 Barnes Blueberry Rd-Test Hole
From To Formation Description
0 30 Sand
30 35 Blue Sticky Clay
35 50 Coarse Gray Sand
50 59 Sand & Dark Clay Layers
59 79 Dark Gray Clay some fine gray sand layers
79 99 Dark Gray Clay
99 125 Fine Gray Sand
125 134 Dark Gray Clay
134 139 Sandy Clay
139 159 Medium sand some clay
159 175 Mostly clay some sand streaks
175 179 Fine Sand
179 193 Fine Sand some clay layers
193 198 Dark gray clay
Jonathan Kamionka
3465-A