GW1-2021-02314_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD Fa hftnal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jason W. Pendley °"� AC WATER
n 0021 FWM TO DESCRIPTION
Weil Contractor Name �UL 2 'L 33 Sand Course
4360 A processing tL 70 ft- Sand
In�olma�i0 5gctp11 M OUTER CASING formulti�ea�ed4iffi OR LIIVIIC Cn ehr
NC Well Contractor Certification Number 0 FROM W DIAtnEI� I THiCKNESS MATERIAL
American Environmental Drilling, Inc. &
Company Name
16. in-
INNERCASING OR TUBIt+iG'- dosed-1
33722 FROM To DIAMElFB TroclarFss nIATExrAL
2.Well Construction Permit#: & 1 i,
List all applicable well permits(i e.County,State Variance,Injection,etc-) R R
is
3.Well Use(checkwell use): c 17:`SCREEN
Water Supply Well: FROM TO I D1A&W1W_I SL4yrs9Z I TMCKNM LMATMAL
❑Agricultural ❑Nbmicipal/Pablic 25 fL 55 'L 14 in 30 1 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) PJResidential water Supply(single) 60 D- 65 R. 4 tO 1 30 1 SCH 40 PVC
❑Industrial/Commerciai ❑Residential Water Supply(shared) 1&=GROUT
FROM TO MATERIAL EMPI.ACJA f METHOD&AMOUNT
0Iffigation 0 ft 20 tz Bentonite Pump
Non-Water Supply Well: R &
❑Monitoring ❑Recovery
R
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19`SANDAGRAVEUPACK a`"is ble
FROM I TO IMATERIAL FdYIPiIACLND:Nl METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 20 & 70 ft Coarse sand Pout
❑Aquifer Test ❑Stotmwater Drainage ft. &
❑Experimental Technology ❑Subsidence Control 20::DRILtiING LOG attach addiiionalAteeb Knece-
❑Geothermal(Closed Loop) ❑Tracer FROM To Dt seRiPnoN color wahock ac
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 to 33 tt Sand
5-15-21 33 n 40 & Clay White
4.Date Wells)Completed: Well ID# 40 R. 50 & sandy Clay
5a.Well Location: 50 ft- 60 & Clay White/Red
David Edmundson 60 fL 70 IL Sand White
Faculity/Owner Name Facilrt3'W#(ifapplicable) IL g,
360 Tufts Vista Jackson Springs, NC 27281 R
Physical Address,City,and Zip :21;REMAM
Moore
County Parcel Identification No.(PIS
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2L Certification:
(if well field,one Wong is sufficient)
35.1699458 N -79.5897626 W
o MRiTeawc9contractor Date
6.Is(are)the well(s): ®Permanent or (]Temporary By siV-g this f—.I hereby cert/fy that the well(s)was(were)constructed in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
If this is a repair.fill ll out(mown well CrWmcdDn information and explain the nature of the ��Site diagram or addltional well details:
repair under#21 remarks section or on the back of rhisform.
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 troll-watersupply wells ONLY with the same canstracdart ou can W11MITrAL I'NSTIJCITONS
submit oneform.
9.Total well depth below land surface: 70 (a) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@200'and 2@100) construction to the following:
45 Division of Water Resources,Information Processing Unit,
10.Static water level below bop of casing: (R) 1617 Mail Service Center,Raleigh,NC 276WI617
Ifwater level is above cwft use
11.Borehole diameter:
8 24b.For Infection Wells ONLY: In addition to sending the form to the address i
Ca)
24a above, also
also submit y of this foam within 30 days of completion of vn
Mud Rotary
12.Well construction method: construction to the following:
r
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Res oD'oes,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
2.5 Method of tes� Pump Zoe.For Water Supply&Inieetion Webs:
13a.Yield(gpm) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 3.49 well construcron to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Bmionment and Natural Resources—Division of WaterResomees Revised Angnst 2013