GW1-2021-06634_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECOIO C X" For Internal Use ONLY:
This form can be used for single or multiple wells 2021
1.Well Contractor Information: 0
Jason W. Pendley OC• np�ocac,'��9� 'I4.WATERZONES :-.'.. _�= ,
�ZlnI> FROM TO DESCRIPTION
Well Contractor Name ,�`� Q1,�1 35 k 75 ft. Sand
4360 A it ft
NC Well Contractor Certification Number IS.-OUTER'CASING for multi iased,wells OR LiNER da 6cable
FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. ft: ft I in
Company Name 16.INNER CASING,OR TUBING eothermal closed-loop)
19393 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft in.
List all applicable well permits fl.e.County,State,Variance,Injection,eta)
IL ft. in.
3.Well Use(check well use): 17.SCREEN,..
Water Supply Well: F18.GROUT-
01ndustrial/Commercial TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public f° 65 fL 4 In 30 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft. 80 f" 4 rn' 30 SCH 40 PVC
(s )❑Residential WateiSupply hared TO MATERIAL EMPLACEMEIYTMETHOD&AMOUNT
❑Irri ation 0 ft. 20 - e• Bentonite Pour
Non-Water Supply Well:
ft. tc
❑Monitoring ❑Recovery
Injection Well: ft ft:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rfa' licable -
FROM TO MATERIAL EWLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRII.LING-LOG attach sdditioffiI sheets if neca§s
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION mlor,hardness,soiUrock type,zmin s¢ eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 & Sand
8-30-21 10 ft. 20 ft. Sand/Gravel
4.Date Well(s)Completed: Well ID#
20 fL 40 ft Clay
Sa.Well Location: 40 fL 75 ft Sand
Holbrook, Lysa 75 ft 80 ft. Clay
Facility/Owner Name Facility ID#(ifapplicable) ft I ft.
489 Carr Lane Raeford, NC 28376 ft. I ft.
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)
34.9838786 N -79.3637706 WZOO.--4., 9-1-2021
ry"'gning
ure of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 ElNo 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#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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 80 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) construction to the following:
0.Static water level below top of casing:
30 (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. 8 (in.) 24b.For Injection 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,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 24c.For Water Supply&Injection Wells:
Also submit one copy of this iform 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Wafer Resources Revised August 2013
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