GW1--04505_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD For Internal Use ONLY:
yThis form can be used for single or multiple wells
1.Well Contractor Information:
Jonathan Kamionka 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 120 ft. 210 ft.
3465-A 230 ft. 250 ft
NC Well Contractor Certification Number 15.OUTER'CASING(for multi-eased wells)OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Bill's Well Drilling Co. 0 ft. 20 ft. 16 in. .250 steel
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WS0601476 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: +1-120ft 210-236t 8 in. SDR21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) - —
250 ft 255 ft* 8 in. SDR21 PVC
3.Well Use(check well use): 17.SCREEN
Water Supply Well: 1FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 120 ft 210 ft. 8 in. .030 SDR17 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 230 ft. 250 ft. 8 t"' .030 SDR17 PVC
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1h GROUT
FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
lalrrigation 0 it. 20 ft• cement poured
Non-Water Supply Well:
❑Monitoring ❑Recovery , 0 ft. 120 ft bentonite pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ' 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
120 ft• 255 ft. #2 gravel poured
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed30.DRILLING LOG(attnehadditbmalsheet if necessary)
Loop) ❑Tracer . FROM TO DESCRIPTION(color,hardnas,soil/rock type,train sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. See Attached
ft. ft.
4.Date Well(s)Completed: 1 1-15-23 Well ID# 1 1 ft. ft.
5a.Well Location: ft. ft.
Blueberry Bay L L C ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
13135 N C Hwy 41, Harrells, NC 28444 ft. rt.
Physical Address,City,and Zip
21.REMARK,S
Bladen
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 11-15-23
Si of Certified Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary 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
7.Is this a repair to an existing well: ❑Yes or ❑No 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: 255 (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@100) construction to the following:
10.Static water level below top of casing: 40 (ft.) 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: 15 (in.) 24b. For Injection Wells ONLY: In 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
13a.Yield(gpm) 400 Method of test: pumped 24c.For Water Supply&Injection Wells:
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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

BILL'S WELL DRILLING CO.
Drilling Log Lithology 11-15-23
BLUEBERRY BAY Back of Farm - Well 11
13135 N C Hwy 41, Harrells, NC - Bladen Co.
From To Formation Description
0 33 Brown sand
33 37 Dark Gray clay
37 57 Fine Gray sand & clay layers
57 80 Dark Gray clay
80 84 sand
84 97 Sand & clay Layers
97 115 Clay
115 120 Sand
120 140 Clay
140 148 Sand
149 151 Rock w/shells
151 157 Sand
157 167 Coase sand
167 177 Fine Sand
177 197 Clay w/sand
197 210 sand
210 237 Clay
237 247 Sand w/rock layers
247 255 hard clay