GW1-2021-06880_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
11tis form can be used for single or multiple wells
1.Well Contractor Information:
Jason W. Pendieyo ATERzNEs D>SCRtox
Well Contractor Name 30 ft 50 ft Sand
4360 A 70 fL 85 ft Sand
NC Well Contactor Certification Number 15.OUTER CASING or mald-cased wells OR LRYER da Lreble
FROM TO I I MATERIAL
American Environmental Drilling, Inc. ft ft. in.
Company Name 16 INNER CASING OR TUBING ermal dose"oo'
32696 ER THIt KNM MATERIAL
2.Well Construction Permit#: f. in
List all applicable well permits(i e.County,State,Variance,Injection,etc.)
ft. in
I
3.Well Use(check well use): 47.SCREEN
Water Supply Well: FROM TO OL&M M SLO[SIZE THICKNESS MATERML`
❑Agricultural ❑MunicipaUPublic 35 ft 70 ft 4 in., 30 PVC
❑Geothermal(Heating/Cooling Supply) DResidential wager supply(single) 80 ft' 85 ft 4 1° 30 PVC
❑Industrilil/COmmercial ❑Residential Water Supply(shared) 18.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 25 Pump
Non-Water Supply Well: p
& ft
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f a Ii able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIe►CEMENTMETHOD
❑Aquifer Test ❑Stomtwater Drainage25 ft- 90 % 1/4 x 1/8 Pour
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if norm"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRirrrox color,hardnes4 soil/re&Mw,mule sim etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 30 It. Sand Clay Orange/White
a.Date Well(s)Completed: 3-29-2021 well ID# 30 ft. 50 fL Sand White
50 & 60 & Hard White Clay
5a.Well Location:
60 ft 170 ft. Sandy White Ciay
Lee Family Farm 2,LLC Jerry Lee
70 ft- 85 ft. White Sand
Facility/Owner Name Facility ID#(if applicable) 85 ft 90 f t. Hard Clay White
12450 US Hwy 15/501 Aberdeen, NC 28315 ft. ft.
Physical Address,City,and Zip r
2L REMARKS,
Moore k
County Parcel Identification No.(P" APR ,.
, 2091
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/longissufficient) ',
'I y r,;cg
35.0973774 N -79.4327365 �, _ / V; 3/31/2021
ature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9 No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and etplain the nature of the
repair under 921 remarks section or on the backof thtsfmm. 23.Site diagram or additional well detags:
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 ifnecessary.
For multiple injection argon-watersapply wells ONLY with the saute consove6an,you Con
submit one form. SUBMITTAL INSTUCTIONS
r
9.Total well depth below land surface: 90 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/f d{$erent(¢sample-3 t(r)200'and 2@100) construction to the following:
10.Static water level below top of casing: 40, (D,) 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. (in.) 24b.For Iniection Wells ONLY:' In addition to sending the form to the address in
Mud Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct pusfi,etc)
Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,FOR WATER SUPPLY WELLS ONLY: �h,NC 27699-1636
20+ Pump 24c.For Water Supply&Injecti�a WeUs:
13a.Yield(gpm) Method of test
Also submit one copy of this form!within 30 days of completion of
13b.Disinfection type: HTH Amount. 3.98 well construction to the county health department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013