GW1-2021-07752_Well Construction - GW1_20211116

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Bobby Lee Allred, II 14.WATERZONES $
Well Contractor Name FROM TO DESCRIPTION
2610-A
ft. ft.
NC Well Contractor Certification Number
IS.-OUTER CASING for'n ti=cased wells OR LINER if a"'licable <.
Charles R. Underwood, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
5J WS 06-0 `'F C 76.'INNER CASING'OR TUBING`" eatherinil closed
2.Well Construction Permit#: V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State. Variance,etc.) +2 ft. 81 ft. 8 in. SCh 10 SS
3.Well Use(check well use): 96-110 fir- 155-159 fit- 8 '"' SCh 10 SS
17.`SCREEN Me z*A i','V a i ;; 22
Water Supply Well: FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
x Agricultural Municipal/Public 81 ft. 96 tr• 8 '"'' .050 IS ch 10 Iss
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 110 ft' 155 fr' 8 '"' 050 1 SCh 10 ISS
Industrial/Commercial Residential Water Supply(shared) -18.GROUTS
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well:._. 0 rt. 3 ft. Cement Poured
Monitoring DRecovery 3 ft, 65 ft• Bentonite Tremie Pipe Pumped
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.'SAND/GRAVELPAC '(if ii"licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 65 ft- 160 ft- #3 Gravel Tremie Pipe Pumped
Experimental Technology [3Subsidence Control H. ft. i
Geothermal(Closed Loop) OTracer 20:DRILLIENG7AGc attach'additioosl`sheetsif oecessa' �., .` .=r-=
Geothermal(Heating/Cooling Return) Other(explain under 921 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)i
ft. ft. See attached formation log
4.Date Well(s)Completed:1 1/05/2021 Well ID#RL-12 ft. ft.
ft. ft.
Sa.Well Location:
NOV
Patten Seed Company ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. f" MR SECTION
McGirt Gin Road, Maxton, NC ft. ft. a, TIONPRXE
Physical Address,City,and Zip
Robeson 193090001007 -21•REMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
34.50.04 N 79.17.58 W
IlI(e�a.l
6.Is(are)the well(s) x Permanent or OTemporary Signature ofC ifie ell Contractor ( Date
_ By signing this,iorm,1 herehv cerq&that the_wehl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or x)No with 15A NCAC'02C'.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
(f this is a repair,fill out known well construction information anti explain the nature of the copy of ihis record has been provided to the well owner.
repair under 411 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 159 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths iJtlifferent(example-3 ct 100'and 2@101P) construction to the following:
10.Static water level below to f casing: 1 5'9 ft.
p o g� ( ) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 17 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
Mud Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) 600 Method of test: Pump 24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 lb completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016

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2000 Boone Trail Road Phone: [phone]
Sanford, North Carolina 27330 ( Fax:[phone]
Patten Seed River Land Farm —IRL-12
34.50.04 N 79.17.58 W
Casing Log
+2' — 81' 8" Stainless Steel Sch 10 Casing
81' — 96' 8" Stainless Steel .050 slot screen
96' — 110' 8" Stainless Steel, Sch 10 Casing
110' — 155' 8" Stainless Steel .050 slot screen
155' — 159' 8" Stainless Steel Sch 10 Casing
• 0'—3'Cement
• 3'—65' Bentonite Grout
• 65'—160' : #3 Well Gravel
I

i
2000 Boone Trail Road Phone:[phone]
Sanford, North Carolina 27330 Fax: [phone]
Patten Seed River Land Farm — RL-12
34.50.04 N 79.17.58 W
Formation Log
0-1 Black Top Soil
1-18 Sand w/ clay lenses, white
18-20 Sand, orange
20-46 Sandy clay
46-60 Sand
60-69 Clay, grey
69-96 Sand
96-110 Sandy clay
110-115 Sand
115-117 Clay
117-144 Sand, chatter
144-154 Sand w/ fine clay�lenses
154-161 Clay w/ fine sand lenses
161-184 Sandy clay

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2000 Boone Trail Road Phone: [phone]
Sanford, North Carolina 27330 Fax:[phone]
Patten Seed River Land Farm — RL-12
34.50.04 N 79.17.58 W
Casing Log
+2' — 81' 8" Stainless Steel Sch 10 Casing
81' - 96' 8" Stainless Steel .050 slot screen
96' — 110' 8" Stainless Steel Sch 10 Casing
110' — 155' 8" Stainless Steel .050 slot screen
155' — 159' 8" Stainless Steel Sch 10 Casing
• 0'—3'Cement
• 3'—65' Bentonite Grout
• 65'—160' : #3 Well Gravel