WQ0040918_GW-1 Forms_20200212

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WELL CONSTRUCTION RECORD For Inmmel Uae ONLY'
Thie form can be used for akgle w multiple wells
' I. Well Contractor Information:
10. WATER ZONES
Thomas Ammons FaoM To oesctdFrrory
Well CwlVdefer Name
2035A
NC Well Commctw Certification Nnmher
Environmental Hydrogeological Consultants,lnc
h.
a
h'
R'
15.011TERCASING for umlti-eeeed wells OR LINER da 8mbk
FROM TO DIAMZTSR TmCrcNH66 MATPRIAL
o a 10 a z is sDn.4o Pvc
Company Neme
2. Well Construction Permit #:
Wst o!f appl/cable well consrrucrtmr pennirs R.e. Couny Sara, Yasiorrce, ac.)
3. Well Use (check well use):
Id.1NNER CASING OR TUBING eotherraM
PROM TO DIAMZTSR
elosWdao
TMICKNPSS
MATF:RLIL
ft, h. iv.
h � N,
17. SCREEN
FROM TO
DIAMa'1'PR
SLOT SIZR
TNICtN'PSS
MATRRIAL
Water Supply Weil:
❑Agriculturel OMunicipal/Public
OGeothermal (Hea[ing/Cooling Supply) ❑Residential Waur Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑kri tion �
10 h' 15 O'
2 ra
.010
Sch.40
PVC
[L tt
iu.
IR GROUT
FROM
TO
MATZRIAL
QNPWCSM®'H'MEI'HOD&AMOUNT'
Neat Cement/Stand-Up
0 ^'
1 h'
Concrete
Non•Wakr supply well:
mMonitoring ❑Recovery
1 h.
g R
Bentonite
Slow Pour Hydrated Pellets
fe
R.
Injection Web:
(]Aquifer Recharge []Groundwater Remediation
OAquifer Smrage and Recovery ❑Salinity Bazrier
❑Aquifer Test OStormuater Drainage
❑Experimental Teclutolagy OSUbaiderree Control
❑iieolhemrel (Closed LOOP) OTraCer
(]Geothermal (Hearin Conlin Retum) OOther ex lain under #21 Remarks
19. SAND/GRAVEL
FROM
PACK
'f0
a ikabk
MATaRNL
RMPLACRMENTMRrROD
g h•
15 R'
No. 2 Filter Media
SIOw Pour
O
R.
20. ))KILLING
FROM
LOG atkeh
TO
admdoaal aheeb ifraaeea
DIiSCaB'f10N wlsr. bard+ea, rca/mek a 'naix,eee
FIDe Sand W/ OCtzsionel Clay bCIuSiDOS
0 f�'
15 fL
12l19/2019 MW-4 B, h.
4. Deh Wells) Completed: Wall ID# B. h.
Sa. Well Location: � ft. R.
Ag Protein, Ina R. fL
FacilityfOwmr Name FacilirylDN lifappliceble) ft ft
420 Bonham Road, Magnolia, 28453 fL h.
Piryaical Address City. and ZiP 21. REMARRs
Sampsori
County Parcel Idemification No. (PM)
56. Latitude and Longitude in degreealmiuutes/secoads or decimeidegrees: 22, Cer rca /�
(ifwell fieM, one latgong is aufficien0 L//Y-✓
78.119284 N 34.86216 N, 12f3112019
c.....M.... .a w.n r•„m.�,em. Dam
6. la (are) the well(s): �Permaoent or OTemporary
7. k this a repair to as eaktirtg well: []Yes or BNo
lJrhis is a repaid f!l ou! brown wrfl consrnadan in/ormarion and erplam the rwarc o(rhe
fir under ='2! remarks sealan or an the back nJrhlsforrn.
8. Number of walla covsfmcted: 4 Ot 4
hbnnulaple injection ornat-unfersupptywelh ONLY widNGs sanm caufnrcdon, you mn
sabmlrone forvn.
9. Total well depth below land surface: 15 (tt)
pormnh/ple wells ldel all depths ifdifferenl (example-3Q100' and 2®!0!Y)
!N signing IMs form, 1 hereby cent Char the ue//(s) was (�rere) cmulrucred m accordurrcr
wl/h JSA NCAC 02Q0/00 ar /SA NCAC O2C .0200 Welf Cmrarn¢tiwt Standards and Thal a
copy offhis rcrnrdhas bean provided In /he we// mvner.
23. Site diagram ar additioual well detaik:
You may use Iha back of dris page to provide additional vrell site details or well
cons(mc[ion deails. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24e. For All Wells: Submit this form within 30 days of completion of well
conslmc[ion ro the following:
10. SM& wakr level below fop of cflsing:
({t,) Division of Water Quality, Informafion Processing Unit,
1617 MeE Service Center, Rakigh, NC 27ti99-1617
/fxmtrr feve/la shove rnsing, rse "��"
diameter; 6.25 (iu,)
246. For Infection Wells: In addition to sending the form to the address in 24a
11. Borehole
above, also submit a copy of this form within 30 days of completion of well
12. Well construction method: HOIIOW-Stem Auger
construction to [he following:
(i.e. auger, rorery, cable, direct push, wcJ
Division of Wakr Quality, Underground Injection Control Program,
FOR WATER SUPPLY W ELLS ONLY:
1ti36 Mao Service Center, Rale(gh, NC 27h99-1636
24c. F W t Sunnly & Infection Wells: In addition to sending the form to
13fl. Yield (gpm) Method offeat:
the addresses) above, also submit one copy of this form withitr 30 days of
completion of well construction [o the county health department of the county
13b. Disinfection type: Amount:
where constructed.
porm l7W.l North Caroline Depamnen[of Environment and Naaaal Resawces-Division oCWaterQwlity Revised Jan. 2019

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WELL CONSTRUCTION RECORD For Imemel Use ONLY:
Thin form can be used far single or multiple wells
1. Wdl Contractor Information:
10. WATER ZONES
Thomas Ammons RaDM TO DESCnDn'tON
WeE ContmctorNeme
2035A
ft. ft
h. fL
NC WeII CaNrector Certification Number PROM T
Environmental Hydrogeological Consultants,lnc o f`• 5
16.INNL7t CA
Company Name PnnM T
2. Well Couafrucdou Permit#:
list all appltcoble we/I construction permiLr (l.e. Caanry, .Slarc, Varianro, amJ
3. Wdl Use (check well use):
❑Agricultural � ❑Municipal/Public
OGeothermal(Heming/Cooling Supply) Residential Water Supply (single)
❑IndustriaVCommemial ❑Residential Water Suppty (shared)
Aquifer Recharge
OGroundwater Remediation
OAquifer Smmge aM Recovery
OSelinily Barrier
OAquifer Test
OStarmwater Drainage
❑Experimental Technology
OSubsidence Control
OGeothermal (Closed Loop)
Tracer
mr'a.s.e....ar rue,.:,.atr,,,.u„o Rebiml
nOther (explain under #2ll
o. Date We6(s) completedo 12I19120t 9 We11 m# MW-3
Sa. Well Lacafion:
Ag Protein, Inc.
Fuility/Owner Nsnu Facility IDO (ifapplicable)
420 Bonham Road, Magnolia, 28453
Plsyaical Address Ciry, and Zip
Sampson
Comty Pnrcel Identification No. (PIN)
5b. LaBtude and Longitude indegrees/miaotes/seeonds or decimal degrees:
(ifwell field, one IeNong u sumdent)
78.119284 N 34.86216 W
ti. Is (are) the well(a): ©Permanent or OTemporary
7. D this a repair m an existing well: Yes or BNo
ljrhis la a repmr jl/ om known sv¢f! construcsion iryjormaston amJerplainthe rminre ojlhc
repair under E21 remarks section or an the back of This form.
S. Number of wells consMucted: `3 Of 4
i�ur mu/!Ip/e Drfecrion or non-xnserruPPly wet/s UNLY w/rh !/u: same emraYnrcamr. you cart
.ruhmil one form.
9. Total well depth below land surface: 15. (ft)
Fornmlllple w¢!Ls bsi olI depths Ifd�rcnr (aramp(a- J sQ3tm' am12O!(NI')
10. Static water level below top oP casing: (ft•1
ljualerlevel is abets msing•nse "+"
11. Borehole diameter: B'25 (in.)
t2. Well constructiau method: HOiIOW-$tem AUger
(i.e. auger, ratery, cable, duect push, etc.)
FOR WATER 5UPPLY WELLS ONLY:
13a. Yield (gpm) Method of test: _
13b. Disinfecdou type: Amount:
fG
R.
f`• � 2 IR � Sch.40 � PVC
S OR TUBING wmermal dosed -too
DIAMETER THICENE55 MATEmAL
R, IR
f1. �•
DLIMETER SLOTSIEE TH[CIWE35 MATERN:
R• 2 1O' .010 Sch.40 PVC
0 m
1 D•
Concrete
Neat Cement/Stand-Up
1 f�•
4 R•
Bentonite
Slow Pour Hydrated Pellets
ft
f4
19. SAND/GRAVEL PACIClifaaulicabie
FROM
TO
MATERIAL
FAtPWCEMENTMETHOD
Slow Pour
4 f`•
15 f0
No. 2 Fllter _Media
R.
R.
20. DRILLING
RROM
LOC sIK<h
TO
admtloaal abe¢O itvecMa
DESCRwT10N(eobr bnNneR wlVroekwoe, eadn e'v¢.ae.l
Fine Sand w! Occasional Clay Inclusions
0 R•
15 f`•
R. ft.
R. ff.
R ft
2 R.
B. R.
R. R.
22. Cart �ica�ien: %`
�//�l/^/��1^-- 12/31f2019
Signature fled Wdi Connector Date
9y signing INis form. ! hereby cerl� Ihat Ibe xm//(s/ was (were) consnrmreAin nccordonce
with ISA NCAC 02C.0100 or l3A NCAC 02C .0200 Well Cmxnrncnon Smrtdartls msAihal o
mpy ofrNls record has been provldeAla the well mvner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site deuils ar well
constmciion details. You may also attach additional pages if necessary.
SUBMITTAL IN_ST_U__CTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
wnswcli0n to the following:
Div'uion of Wafer Quality, Information Processing Unit,
1617 Ma6 Service Cenfeq Raleigh, NC 27699-1617
246. For Iniectiou Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this fomr within 30 days of completion of well
consimUion to the following:
Division of Water Quality, Underground Injection Control Program,
IG30 Mail Service Center, Raleigh, NC 27699-1636
24c F W t r 3 DDIv & Infection Wells: In addition to sending the farm to
the addresses) above, also submit one copy of This form within 30 days of
completion of well constmctien to the county health department of the county
w7aere constructed.
Porm GW-1 North Carolina Depenment ofEnviranaunl and Nabirzl Resomcea-Division of Water Queliry Reeised Jan. 2013

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
Thie form can be used for si�Ie armulliple wells
1. Web Contractor Information:
1/. WATER ZONES
Thomas Ammons FaDa, 'trr Dr3CRIPTION
Well Commcwr Name fr'
2035A - ^ "
NC Well Contractor Cenification Number
Environmental Hydrogeological Consultants,lnc
Company Name
2. Well Conatruction Permit#:
IJst all applicable welt caretrneaon permld (f.e. Camrry, Smte, Yarimrce, eml
3. Well Use (cheek well use):
OAgricultural
OGeothermal (Heating/Cooling Supply)
Olndus[riel/Commercial
OAquifer Recharge
OAquifer Smrage and Recovery
❑Aquifm Test
❑BxperimenWl Technology
❑Geothermal (Closed Loop)
Municipal/Public
oResidential Water Supply (single)
Residential Water Suppy (shared)
i 0 R• i 10 ra i 2 is � Sch.40 � PVC i
R a.
R. a
10 n � 20 ft• � 2 td � .010 � Sch.40 i PVC i
R. ft. im
0 �' 1 fr. Concrete Neat Cement /Stand -Up
1 *'• 9 rc 8entonite Slow Pour Hydreted Pellets
I— n. tti
Groundwater Remediation
1
OSalinity Bmrier
P
9
OStonnwater Drainage
Subsidence Control
2
OTmcer
a
G
nftther lexolain under #21 Remarks)
4. Dare wen(a) Completed: 12/19/2019WreD tD# MW-2
Sa. Well Location:
Ag Protein, Inc.
Fadlity/Owrres Neme Facility IDk (ifapplicable)
420 Bonham Road, Magnolia, 28453
Phyeicel Address, City, aM Zip
Sampson
County Pucel Idemificetion No. (PIN)
a• i No. 2
rc i20 m I Fine Sand w! Occasional Clay Inclusions
h.
R
n.
R.
ik
fr.
rt.
a
n.
n.
u.
rt.
56. Latitude and Longitude in degreealminutee/seconds or decimal degrees: 22. Certificalrolt:
(ifwell field, ono leNlonghsufficirnt) � A� �
78.119284 N 34.86216 w
6. to (are) the we6(s): �Permanenf or �Temporery
7. is this a repair m an existing weD: OYes or �No
{jlhis Isa mparr, frll orst krmrwr well cxrulmetlxn it farmatian and arplam the Holum ujdie
mpatr uMer d21 remarkr senlmr or on the hack of this form.
8. Number of wells constructed: 2 Of 4
hbr muh/ple irJection anion-xnterneppty wells ONLY x�idt the smm conshxraan, you cart
sabmn one form.
9. Total well depth below land surface: 20 (R.)
Far nmhiple wells lisi xfl dePrhr ifd�emnl (eranrfde- 3Q200' and 2(a3/0d)
18. Static wafer Ievei below top of casing: (ft.)
{jwalerlmeiis abo,re ca.Wng, use "+"
11. Borehole diameter: 6.25 (in.)
l2. Weu consMuciion method: HOIIOW-Stem AUger
(i.e. augen rotmy, cable, direct push, etc.)
FOR WATER SUPPLY W ELLS ONLY:
13a. Yield (gpm) Method of rest:
13b. Dfalnfection type: Amount:
\�,�1 J 12l31/2019
Signature of 'fi ell Contracmr Dare
9y signing This form. 1 hereby certify dm1 the sval!(s) was (mere/ ronnn¢ted iu attrorrfance
mith l3A NCAC dIC.0100 ar 15A NCAC 01C .0200 Well Cfmrrpumion Smndardr mid that a
ropy of this mrord imr been provided m thx well turner.
23. Site diagram or additional well demils:
You stay use the back of [his page to provide additional w+eil site details or well
consiroctien details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit [his form within 30 days of completion of well
constmction to the following:
Division of Water Quality, Information Processing Unit,
1617 Meil Service Center, Raleigh, NC 27699-16t7
246. For Inieetion Wails: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
constmction to the following:
Division of Water Quality, Ilndcrground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27499-I(r36
24c. For Water Sunoly &Inieetion Wells: In addition to sending [he form to
the addresses) above, also submit one copy of this form within 30 days of
completion. of well construction to [he county health department of the county
where constructed.
Fonn GW-I North Carolins Depamnent of Environment and Natural Resouroes—Division of Wakr Qtwlity Rer•ised lan. 2llli

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WELL CONSTRUCTION RECORD 'Y`� t2 � ��� �� Forin[emelUseONLY:
This roan eenbe used for einglo or multiple walls
I. Well Contractor Information
14. WATER ZONES '
Thomas Ammons maoM To DEscRaT�oN
WeR Covtmctor Name
2035A
NC Well Contractor Cettificedon Number
Environmental Hydrogeological Consultants,ine
R. ff.
rL ff'
IS. ODTERCASING tormNtlsexd weW ORI.WER sta 61e
FROM TO DNMRfER TRICKIS833 MATBRIAL
o R• 10 R z is Sch.40 Pvc
Company Neme
2. WeE Construcfioa Permit #:
LGI al(applicable well mnstruc/ion permi(s (i.e. CmmN. Smte. Parlance. etc)
3. WeD Use (eheekwell use):
16.INNRR CASDVG ORTURDiG mal
rloxddoo
PROM TO DIAMETER
THIC8NP53
MATERIAL
R. tL '"'
i6 ff. in.
17. SCREEN
FROM TO
DIAMETER
SLOTSIZR
THICRN893
MATERIAL
Water Sappy WeD:
❑Agriculmml oMunicipal/Public
❑Geothermal Heatin Caolin Su 1 �Residentiai Water Su I sin le)
( g/ g PP Y) PP Y ( g
OIndtistriaVCommercial ❑Residential Water Supply (shared)
❑Irri tion �
10 ff' 20 tL
2 a°'
.010
Sch.40
PVC
ff. it
in
1E.CROIIT
BROM
TYI
MATBRNL
EMPLACBMRNr MRTHOD&AMOUN
Neat Cement /Stand -Up
0 ff•
1 R•
Concrete
NoD-Water Supply Well
mMonitoring Recovery
1 D.
9 ff.
Bentonite
Slow Pour Hydrated Pellets
ff.
PL
IujeeOon WeD:
❑Aquifer Recharge OGroundwe[er Remediation
❑Aquifer Stange and Recovery Salinity Barrier
Aquifer Test OStormwater Drainage
❑Experimemal TechnDlogy OSubsidewe Control
OGeothermal (Closed Loop) - 17Tracer
�Geothennal (Head Cooling Retum) Other ex lain under#21 Remarks)
19. SAND/GRAVEL
PACK
Ra bk
FROM
TO
MATBRW.
EMPIACEMBNTMETR00
g ff•
20 rL
No. 2 Filter Medic
Slow Pour
ft
a
.
tA. DRR.LIXG
LOG etfaeh
additiarelahxbifnecuaa
PIIOM
TO
DESCRR`TION edonaaMocy wtrmak ' sue,ee
0 ff•
20 fL
Fine Sand W/ Occasional Clay Inclusions
12J19/2019 MW-1
4. Dah Weil(s) Completed: Well ID#
Sa. Well Location:
A9 Protein, Inc.
Facility/Owner NMne Facility lDa (iEappBceble)
420 Bonham Road, Magnolia, 28453
�
�
R,
(L
R
a
2
rL
D,
ff.
.
R.
rc
Plrysicel Address, City, and Zip
Sampson
2I, REMARKS
County Parcel ]dendficution No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifweli fteld, one Iallong is sufficient)
78.119284 M 34.8621 ti
6. D (are) the weD(s): ©Permanent or OTemporary
7. Is tbis a repair to an ex(sdng weD: OYes or 0No
Iflhis h�a repair, fill out prawn well cansbucfipn Infarmatbn and esp/ain the rmmre ojlhe
repots udder a2/ remarks seellon or on the back oflNtrfonn.
S. Number ofwells conafrneted: � Ot 4
1% Ir' l "eetlmr or pore-seatersa pl wells ONLYwNh the same eamm�etian you con
22. Cerli ca n:
12/31/2019
Signawreo C W ell Contractor Dere
IIY signing Mfs faros, 1 hereby arrrjy (Nat the wel!(sJ ryas (we J connrucred ftt accordance
wfrh l5A NCAC 02C .0f00 or /SA N(.'AC tl2C.0200 Well Cmas(n¢timr Slonrkrds and that o
copy of this rewrd has been provided ro the wel(awner.
23. Site diagram or additional well demils:
You may use the back of this page to provide additional well site details or well
wnstmction details. You may also attach additional pages if necessary.
ar mu rpemJ P Y
submit mse fornr.
SUBMITTAL INSTUCTIONS
9. Total well depth below laud surface: 20
tft.)' 24a. Far Ail Wells: Submit this form within 30 days of completion of well
Pannuhiplewe/ls list a((depdrs ifdpererrt (era �e-3(�200'andlrsCl00')
cons[metion to the following:
10. Sta0e water level below tap ofcasing:
(ft.) Division or Water Quality, Information PracessiRg Unit,
JrwarerlesNlls abosre casing, are "+••
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter; 625 (im)
246. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
Hollow -Stem Au er
12. WeD construction method: g
consimction to the following:
Q.e. auger, rotary, cable, duct pmh, etc.)
Division of Water Quality, Underground InJeedeu Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. Fnr Water Snnnly & [uicefion Wells: in addition to sending the form to
13a. Yield (gpnr) Method of teat:
the addresses) above, also submit ono copy of this form within 30 days of
completion of well cons[metion to the county health department of the county
13b. Disinfection Amount:
rye°
where canstmcted.
FonnCW-I Nonh Carolina Department ofEnvirdnmem and Naltual Remnrws-Division of Water Qnaliry Ravued Jm,. 20I3