GW1--07651_Well Construction - GW1_20231204

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14c WATER ZONES :._ .:k;
Jason W. Pendley FROM TO DESCRIPTION
Well Contractor Name 35 it. 55 ft. I ; Sand
4360 A 65 ft. 115 ft. I j Sand
NC Well Contractor Certification Number
=15:OiTi'ER'CASING'(foFm ill sed welli)'OR`LINER.(ifan licnble) `_`
FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. n• ft. in.
Company Name 16:11VNER CASING UR TUBING,(>eotbermni doscvlloop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: 562 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) -
ft. ft. in.
3.Well Use(check well use): .17siSCREEN' - `y ,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL
❑Agricultural ❑Municipal/Public 75 ft- 110 ii• 4 in. 30 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) 115 ft- 120 ft- 4 in- 30 SCH 40 PVC
38 GR01TT i ;_.
❑Industrial/Commercial ❑Residential Water Supply(shared) •FROM To MATERIAL EAIPLACE\IEhT METHOD&AMOUNT J
❑Irrigation 0 ft- 22 n• Bentonite Pour 6 Bags
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDIGRAVEL PACK(if iiinlielibley'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier •
22 ft 120 ft- 1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage
n. it.
❑Experimental Technology ❑Subsidence Control
20:DRTL'LING.LOG(attach"additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks). 0 ft- 28 n, Sand
11-13-23 28 n, 35 n, Clay
4.Date Well(s)Completed: Well ID# 35 ft- 55 ft- Sand
Sa.Well Location: 55 ft- 65 it, Clay
Joel & Cassie Wallskog 65 ft- 115 n• Sand
Facility/Owner Name Facility ID#(if applicable)
2859 ArmyRoad Raeford, NC 28376 115 ft 12o n• clay
ft. ft.
' Physical Address,City,and Zip `21',REMARKS : k_?5 I(.5 :-r -
Hoke ��}}
County Parcel Identification No.(PIN) D , it _ 2 G 23
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Inc m =`C.1 `)1..141'
(if well field,one lat/lone is sufficient) DI ij�,^O Lr
35.04492 N 79.38453 W i% cT r� 11-22-2023
Sign-.re of Certified Well Con[mcto' Date
---6:Is(are)the well(s):-1 Permanent—or- ❑Temporary --- _ _
'Bv signing this form, -in-accordance--
with with 15d NCAC 02C.0100 or ISA NC.-IC 02C.0200 1!•'ell 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 known well construction information and explain the nature of the
repair under#21 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 same 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 ifdtlferent(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,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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
Mud Rotary
12.Well construction method: 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(gpm) 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 courityi 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