GW1-2021-00090_Well Construction - GW1_20210506

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Page 1
Submission ID#
CONTACT INFORMATION
............................................................................................................................... ..........
Email Address*
Contact Name* wend [e-mail]
William Grant Floyd m
Is this a revision to the form you have previously submitted?
r Yes F No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4399 A WILLIAM FLOYD WENDELL LEE WELL SERVICES INC
2.Well Construction Permit#:
EH-21242
List all applicable well construction permits(i.e.IVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

4/12/2021 P87-314 60
(gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
James Robert Talbert Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Polk P87-314
Physical Address* Street Address
280 Renard Road
Address Line 2
City State/Province/Region
Tryon NC
Postal/ZZp Code Country
28782 US
Latitude* 35.2162660000 Longitude*82.1401270000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain 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
120 surface?
For multiple wells Iistall depths if different 82
(example-3 a200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
55 6.125
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
60 13a. Method of test:
If applicable AIR
13b. Disinfection type:* 13b.Amount:*
HTH(Granular) 12 oz.

14.WATER BEARING/FRACTURE ZONES
From To Description
93 97
in feet in feet
100 103 40 gpr
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 -82.00 6.12 SDR-21
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
0.00 0.00 0.00
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 Concrete Mix and Pour(16 Bags)
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
0.00 NONE
in feet in feel
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 45.00 Red Dirt
in feet in feet
45.00 75.00 Brown and Red Clay
in feet in feet
75.00 82.00 Soft Gray Rock
in feet in feet
82.00 93.00 Gray Rock
in feet in feet
93.00 99.00 Black Rock
in feet in feet
99.00 120.00 White Rock
in feet in feet
21.Remarks

22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
*I7 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*
r1l�Za� cP,��l
Signature of Certified Well Contractor
Submittal Date 5/6/2021