GW1-2021-03021_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:
1.Well Contractor Information:
Jason W. Pendle 14 WATERZONES
Y FROM To DESCRIPTION
Well Contractor Name 30 fL 45 fL Sand
4360 A 60 IL 85 M Sand
NC Well Contractor Certification Number >IS'OUTER CASING r math-eased Wells OR LINER d "'6c5ble
FROM TO DIAMErER THICKNESS MATERIAL
American Environmental Drilling, Inc. ft. fL 1 in.
Company Name 16.INNER:CASING OR TUBING hiaothirmud closed400til
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 456 R. fL
;n.
List all applicable well permits(I e.County,State,Variance,injection,etc.) fLt. f
t.
3.Well Use(check well use): :-iZ
Water Supply Well: FROM I TO DIAMETER I SLOT SEEE I TEXIOWSS I MATERIAL
❑Agricultural ❑MunicipaMblic 40 ft- 75 fL 4 in. 30 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) LlResidential Water Supply(single) 80 ft' 85 ft 4 in- 30 sch 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) " GROUT
❑Irri anon
FROM TO MATERIAL EMPiACEMMT METHOD&AMOUNT
0 ft. 20 fL Bentotiite Pump
Non-Water Supply Well:_____ _- ______ �—_-
- - _ R. ft.
❑Monitoring ❑Recovery
Injection Well: M R.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL`PACK ifa liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATES I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 fL 90 1/4 x 1/8 Pour
ft. fL
❑Experimental Technology ❑Subsidence Control
10.DRILLING LOG attach ndditionil-sheeb.ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRiMOx color hardn wiUrack etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other lain under#21 Remarks) 0 fL 20 f- Sand
4.Date Well(s)Completed: 5-3-2021 Well 1D# 20 fL 30 IL Clay
30 ft. 45 it. Sand
So.Well Location: 45 fL 160 M Sand Clay
Kim Berger
60 'L 85
Facility/Owner Name FaclityM#(if applicable) L 0 R. Sand
540 Nighthawk Loop Aberdeen, NC 28315 85 90 ) 1 Rock
fL
Physical Address,City,and Zip 21 REMARKS
Hoke
County Parcel Identification No.(PIN)
^r►�:aC;on prduf:ssln
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: v t '
22
(if well field,one InWong is sufficient) Certification:
35.0664729 N 79.4176329 at
Si of Certified Will Contractor Date
-- Is6 (are-thew—le i(s):OPermanent or ❑Tem sporary -- ---- - - --- -- -
By fining this form,I hereby certff that the l(s)wass(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Weft 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!mown well construction information and explain the nature of the
repair under#21 remar/a 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
S.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 coresvuedon,you can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 90 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3Q200'and 2(a3100) construction to the following:
10.Static water level below top of casing: 35 UP Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 20 plus Method of test: Pump 24c.For Water Supply&Injection Wells-j
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 4.07 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