GW1-2021-02763_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jason W. Pendley .14.WATER�' DESCREMOx
Well Contractor Name 30 R• 50 & Sand
4360 A 70 n 85 fL Sand
NC Well Contractor Certification Number 15.OUTER CASING or mniti-eased was OR LINER d8 Ficahie
FROM TO DIAhWrER TffiCKNESI MATERIAL
American Environmental Drilling, Inc. fL ct. in.
Company Name .16.INNER CASING OR TUBING thermal dosed too
32696 FROM TO DIAMETER TFUCKN SS MATERIAL
2.Well Construction Permit#: & fL in.
List all applicable well permits(Le.County,State,V-1ance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: mom TO DIABIL"M sl arSVE TWCEMM MATF UL
OAgriculturat ❑Municipal/Pubiic 35 k' 70 R 4 11 30 PVC
[]Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 80 R• 85 D' 4 1II' 30 PVC
18 GROUT
❑IndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMMhILMOD&AMOUNT
0Irri ation 0 25 Pump
Non-Water Supply Well:
[t. fI.
❑Monitoring ❑Recovery
Injection Well: tt &
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a livable ;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EN7MCEMENTMMHon
❑Aquifer Test ❑StormwaterDrainage 25 ft 90 1/4 x 1/8 Pour
& @.
❑Experimental Technology ❑Subsidence Control 10.DRILLING LOG'attach addition
al aal sheers if necessa'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRWHOx color,hardnes4soatmex, n sae etu
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 0 D• 30 R• Sand Clay Orange/White
4.Date Well(s)Completed: 3-29-2021 well ID# 30 ft 50 Sand White ft•
50 60 Hard White Clay
5a.Well Location:
60 170 & Sandy White Clay
Lee Family Farm 2,LLC Jerry Lee
7() ft• 85 a• White Sand
Facility/Owner Name Facility M#(if applicable) 85 fL 90 R• Hard Clay White
12450 US Hwy 15/501 Aberdeen, NC 28315 R
Physical Address,City,and Zap 21.REMARKS '"'o
r
Moore ` ul
County Parcel Identification No.(PIN) I APR ,.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,out lat/long is sufficient)
35.0973774 N -79.4327365 W3131/2021
tureofCertifiedWell Contractor Date
6.Is(are)the we➢(s): ®Permanent 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 FINo copy of this record has been provided to the well owner.
If this is a repair,fill out known well conorrtction information and aWlain the nature of the
repair under 921 remarks section or on the backof thisform. 23.Site diagram or additional well detains:
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 canouedon,}rill can
submit one form. SUBMITTAL INSTUCTIONS
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 if different(example-3(a)200'and 2@100) construction to the following:
10.Static water level below top of casing: 40' (g,) 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 Infection Wells ONLY: In addition to sending the form to the address in
Mud Rota 24aabove, 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,detect push,etc)
Division of Water Resources,Underground Igjection Control Program,
C 16M Matz Service enter,Raleigh,NC 27699-16M
FOR WATER SUPPLY WELLS ONLY:
20+ Pump 24c.For Water Supply&Injecti f I n;Wells.
13a.Yield Wm) 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 when:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013