GW1-2021-06660_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD . � For Internal Use ONLY:
This form can be used for single or multiple wells p�
1.Well Contractor Information: O t^I T
Jason W. Pendley WATERZONEs
€ctC�gPROM TO I DFSCRIMON
Well Contractor Name p[1 �;pn 220 ft 260 ft Quartz Rock Mix
4360 A ��+�o ptiN� ft. ft.
NC WellContraaorCeRificationNumber 15.OUTER'CASING foruiulti-cas`ed:wells ORIdNER da' licable
FROM TO DLIMF.TEIt THICIINESS MATERIAL
American Environmental Drilling, Inc. 0 ft. 90 ft 6 SCH 40 PVC
Company Name 16.INNER CASING OR TUBING 'eothermal closed400
35425 FROM TO DL►MUM THICIINESS MATERIAL
2.Well Construction Permit#: 0 ft 230 ft 4 'n SCH 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. R
in.
3.Well Use(check well use): 17.SCREENL
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
110 f
❑Agricultural ❑MunicipaVPublic 125 ft 4 in. 30 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 195 ft 215 ft- 14 h 1 30 1 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 118.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigation 0 ft. 20 ft Bent6nite Pump
Non-Water Supply Well: R it
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19:SANDIGRAVEI.PACK(if applicable)
FROM TO MATERIAL EMPIACEMENr METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 100 ft 230 ft 1/4 z 1/8 Gravel Pour
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach additional sheets if ueeevssi
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIMON color,hardness,soiilfto&type,grain sae,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 20 ft Clay
9-7-21 20 ft 40 ft Sand
4.Date Well(s)Completed: Well ID#
40 ft 80 ft Grey Clay
5a.Well Location: 80 ft 90 ft Grey Rock
Latitude Builders Manning 90 ft 210 ft Rock Grey
Facility/Owner Name Facility ID#(if applicable)
105 Foxwood Close Lane Cameron, NC 28326 210 23o ft Quartz Rock
&
ft ft.
Physical Address,City,and Zip 21.REMARKS
Moore
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)
35.3317029 N -79.3325127 a, r o�
gnature or Date
We i Contractor Date
6.Is(are)the well(s): 91Permanent 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 EINo 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 921 remarks section or on the back ofthisform. 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 consruction,you can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 230 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3 a@200'and 2@1001 construction to the following:
10.Static water level below top of casing:
55 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
8 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy ofthis form within 30 days of completion of well
12.Well construction method: Mud Rotary 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
i
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 8 Method of test Pump Also submit one copy of this form within 30 days of completion of
13b.Disinfection type. HTH Amount: 6.41 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