GW1--07650_Well Construction - GW1_20231204

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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
ATER>ZONES fi DESCRH'TIO
Well Contractor Name 35 R• 55 R• I ' Sand
4360 A 65 R• 115 R• I Sand
'15.OUTEIRCASING(formnl6'cused'avelts)ORL'INER(ifap lieable) ':
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. R. ft. i
in.
Company Name 4'-'1&INNER CASING;OR T IlBIPIG(geottiermal clased?loop).. ;_
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 563 R. R. In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
R. R. in.
3.Well Use(check well use): :17 SCREENnr _ .Z . - _ ,..
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
75 R 110 R• 4
• ❑Agricultural ❑Municipal/Public in- 30 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) 115 R• 120 R• 4 ft' 30 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18°GROUT.: :i; :. :'
FROM TO MATERIAL EMPLACEMENT METHOD&A,NIOUNT
❑irrigation 0 ft- 22 R. Bentonite Pour 6 Bags
Non-Water Supply Well:
K - R' -- —
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19°SAND/GRAVEL-PACK(If applicable) .f -: s =_-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier22 R• 120 R 1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage
R. R.
❑Experimental Technology ❑Subsidence Control
.
30:=DRILLiNGLsQG(attach udditionnlstieetsdnecessory) _---
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soli/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R• 28 R. Sand
11-13-23 28 ft- 35 R• Clay
4.Date Well(s)Completed: Well ID#
35 if. 55 n• Sand
5a.Well Location: 55 R• 65 R• Clay
Joel & Cassie Wallskog 65 R• 115 R• Sand
' Facility/Owner Name Facility ID,+(if applicable)
2859 ArmyRoad Raeford, NC 28376 115 R. 120 R• clay
R. R.
• Physical Address,City,and Zip 21:REMARKS 1
.. Hoke •. •--- ,,-•g. V - ' J?
County Parcel Identification No.(PIN) (JC�' 7--.:.°��
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) lU'"' r-•` t'�
35.04492 N 79.38453 . �� c�, r i L vs''-'= °,3'3 1r1-22-2023
Sign-.re of Certified Well Contracts Date
6;Is(are)the well(s): faPermanent - or ❑Temporary - -By signing this form,I herebv-cerfh;that the well(s)-was(were)constructed in accordance_--_
with 114 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of this record has been provided to the well owner.
If this is a repair,fill out biotin well construction it formation and explain the nature of the
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 sane construction,you can' -
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 120 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij/erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water,Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8 (in.) 24b.For Injection Wells ONLY: 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
12.Well construction method: Mud Rotary construction to the following:I
(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
20 plus Pump 24c.For Water Supply&Injection Wells:
13a.Yield(gym) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 7.05 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013