GW1--03102_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
I.Well Contractor Information:
Jason W. Pendley14.WATER ZONES
FROM • TO DESCRIPTION
Well Contractor Name 20 ft 102 ft Sand
4360 A 120 ft 150 ft Sand
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
American Environmental Drilling, Inc. ft rt. in.
Company Name 16.INNER CASING OR TUBING(geothermal clased400p)
50199 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
❑Agricultural ❑Municipal/Public 90 ft 110 ft 4 in. 30 SCH40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 120 ft. 135 ft. 4 in. 30 SCH40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) IS•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
$llrrigation 0 ft 22 ft. BentoniteChip Pump
Non-Water Supply Well:
ft. ft.
0 Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
22 ft 150 ft 1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 5 ft. Soil
4-28-2024 5 ft 20 ft Sandy Clay
4.Date Well(s)Completed: Well1D#
20 ft. 102 ft Sand
5a.Well Location: 102 ft 120 ft Clay
Timmy Adams fL ft
120 150 Sand
Facility/Owner Name Facility ID#(if applicable) ft. ft
121 Eugene Street Aberdeen, NC 28315 ft ft. _
Physical Address,City,and Zip 21.REMARKS
t -(...., )," L 1/
Moore
County Parcel IdentificationNo.(PIN) 1• n ,'r'Y � L [G 4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient) I rt...': - • . "" •i jr,k.
35.18279 N 79.50607 W 2, � l.f? t;:;: '-A 8-2024
Signr-re of Certified Well Contractor Date
•
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ONo 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: 150 of,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di ferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing 50 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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.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
20plus 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.DisinfectionHTH Amount: 11.75 well construction to the county health department of the county where
type: constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013