WQ0040918_Other_20200215

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
Thomas Ammons
Well Contractor Name
2035A
NC Well Contractor Certification Number
Environmental Hydrogeological Consultants,lnc
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothemtal (Heating/Cooling Supply)
❑ htdustrial/Commercial
❑ Irrigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
❑Municipal/Public
El Residential Water Supply (single)
❑Residential Water Supply (shared)
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 F
4. Date Well(s) Completed: 12/19/2019 Well ID# MW-1
5a. Well Location:
Ag Protein, Inc.
Facility/Owner Name Facility ID# (if applicable)
420 Bonham Road, Magnolia, 28453
Physical Address, City, and Zip
Duplin
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
78.119284 N 34.86216 W
6. Is (are) the well(s): ❑] Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
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.
8. Number of wells constructed: 1 Of 4
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 20 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.25 (in.)
12. Well construction method: Hollow -Stem Auger
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
rt.
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER if a licable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
10 rt.
2 in.
Sch.40
I PVC
16. INNER CASING OR TUBING eother a] closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
10 ff
20 ft'
2 in.
.010
Sch.40
PVC
ft.
ft,
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 rt.
1 IL
Concrete
Neat Cement / Stand -Up
1 rt.
9 ft-
Bentonite
Slow Pour Hydrated Pellets
rt.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
9 rt.
20 rt.
No. 2 Filter Media
Slow Pour
rt.
rt.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
0 rt.
20 rt.
Fine Sand w/ Occasional Clay Inclusions
rt.
rt.
ft.
ft.
rt.
rt.
rt.
rt.
ft.
ft.
rt.
rt.
21. REMARKS
4\'Z
cati Jt:
02/17/2020rev
n e of Certified Well Contractor Date
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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Injection 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: Amount: completion of 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 Quality Revised Jan. 2013