GW1--02450_Well Construction - GW1_20240423

it
WELL CONSTRUCTION RECORD• For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jason W. Pendley14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 12 ft. 44 ft• I 1 Sand
4360 A 48 ft. 107 ft• 1 1 Sand
NC Well Contractor Certification Number 15.OUTER CASING(for multi,cased wells)OR LINER(if ap ficable)
FROM TO DIAMETER , THICKNESS MATERIAL
American Environmental Drilling, Inc. ft. ft. i in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
48743 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public 58 98 •ft 4 'O 30 40 PVC
❑Geothermal-(Heating/Cooling Supply) ❑Residential Water Supply(single) 105 ft• 110 ft. 4 in' • 30 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 20 ft. Bentonite Pump
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier 20 ft• 110 ft• 1/4 X 1/8 Pour
[Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology CI Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiLrocktype,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 12 ft. I Sandy Clay
2-22-2024 12 f` 44 f` Sand
4.Date Well(s)Completed: Well my •
44 ft. 48 ft. i Clay
5a.Well Location: 48 ft. 107 ft. Sand �,i�:>
' ,i� :i..�`
L & E Legacy Holdings ft ft °- �"
107 110 . , Clay r ;�2
Facility/Owner Name Facility ID#(if applicable) ft ft. A F R 2 `a `
133 Maxie Lane PI, Aberdeen, NC 28315 ft r,. ,; j
Physical Address,City,and Zip �,.<..;;r�i;u., : ,�+)`
21.REMARKS T .i
Moore i,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.13249 N 79.52068 '
W 2, r� 2-22-24
Sign-.re of Certified Well Contracto• Date
6.Is(are)the well(s): IPlPermanent or ❑Temporary By signing this form,I hereby certify that;the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 92C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 I
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 atiach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 10 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 4200'and 2@l00`) construction to the following: 1'
10.Static water level below top of casing: 47 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
Mud Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Ce}ter,Raleigh,NC 27699-1636
20 gpm Method of test Pump 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Also submit one copy of this form`within 30 days of completion of
13b.Disinfection type: HTH Amount 4.93 well construction to the county health department of the county where
constructed. I I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources urces Revised August 2013