GW1--02465_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
1.Well Contractor Information:
Jason W. Pendley FROM
WATER ZO TONES DESCRIPTION
Well Contractor Name 12 ft. 32 ft I 1 Sand
4360 A 100 ft 125 ft I Sand Clay Mix
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(id ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. ft. ft in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
76088 FROM TO DIAMETER THICKNESS ; MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft i in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER ! SLOT SIZE . THICKNESS MATERIAL
I:Agricultural ❑Municipal/Public 30 it 45 ft 4 in-1 30 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 95 ft. 125 ft 4 rn' 30 SCH 40 PVC
❑IndustriaUCommercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 22 ft. Bentonite, Pump
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM • TO MATERIAL; EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 22 ft 125 ft• 1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control II
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 10 ft ;' Sand
3-20-2024 10 ft 12 ft Clay
4.Date Well(s)Completed: Well ID# ft ft
12 32 Sand
5a.Well Location: 32 ft. 100 ft Hard Clay
Matt Vincent 100 ft. 125 ft• i Sand Clay Mix
Facility/Owner Name Facility ID#(if applicable) ft. ft.
177 Perry Leviner Road, Hamlet, NC 28345 ft. • ft. :r•,
Physical Address,City,and Zip 21.REMARKS . 4 ` a'""-I` 4 L`"
Richmond i' APR 9 Ld74
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: + irf"'r.S. :'.r)•',.ti.ti Ais.:,'2, ',JAI
(if well field,one latflong is sufficient) • DV COCK?)
34.82004 N 79.79669 W -. 2, 3-20-2024
Sign,- of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the j
repair under 1121 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 l•
9.Total well depth below land surface: 125 (ft)
24a. For All Wells: Submit thus form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: I'
10.Static water level below top of casing: 69 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
8
11.Borehole diameter: (in.) 246.For Infection 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: ry construction to the following: :
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service;Center,Raleigh,NC 27699-1636
7.5gpm Pum 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: p
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount 4.38 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 Water Resources Revised August 2013