GW1-2021-06633_Well Construction - GW1_20211007

1
WELL CONSTRUCTION RECORDyp For Internal Use ONLY:
This form can be used for single or multiple wells rr
1.Well Contractor Information: ,
Jason W. Pendley O (.4ti 14:'WATER DFSCREMON
Well Contractor Name °CQ�r�1t� 0 D 65 ft-
. i Sand
4360 A ,3r�NR�e°�'0n 75 fr. 95 fL Sand
NC Well Contractor Certification Number �n{ 15 OUTER.CASING for multi cased we0s OR LINER tf a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. ft
IL
in.
Company Name 16.'INNER CASING OR TUBING eot4ermal dosed-loo
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 473 ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. &
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSIZE L THICKNESS IMATERIAL
❑Agricultural ❑Municipal/Public 40 ft' 60 ft' 4 rn 1 30 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 80 2 100 fL 4 tn. 30 SCH 40 PVC
❑lndustriaVCommercial ❑Residential Water Supply(shared) 1&GROUT ;
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20 rL Hole Plug Pour
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
ft. fa
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK If a' licable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 20 fL 100 ft '1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage R, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necwsa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMOx color,Iwdo sofvro& la sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 & 20 ft Sand
9-10-21 20 30 & Sandy Clay
4.Date Well(s)Completed: Well MNtc ft
30 65 Sand
5a.Well Location: 65 iL 75 ft
Erin Erin Dallas 75 fa 95 Sand
Facility/Owner Name Facility ID#(if applicable)
305 Arthur Lane Aberdeen, NC 28315 95 ft' 100 ft. Clay
f4 fL
Physical Address,City,and Zip 21.REMARKS'
Hoke
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)
-79.3748737 9-10-21
35.0824154 N �,
ofCertified Well C tractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy ofthis 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 cons&ucdon,you can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 100 (ft) 24a. For All Wells: Submit j this form within 30 days of completion of well
For multiple wells list all depths ifdifjcrent(example-3@200'and 2 t@1001 construction to the following:
10.Static water level below top of casing: (�)
30 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
8 (in.) 24b.For lniection 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: j
(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) 15 Method of test: Pump For Water Supply&Injection Wells:
Pump Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount. 4.37 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 W Revised August 2013
ater Resources
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