GW1--05954_Well Construction - GW1_20241009

'
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 30 ft. 60 ft. I Sand
4360 A ft. ft. i 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
American Environmental Drilling, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
51917 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(Le.County,State,Variance,Injection,etc.) ft. ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 45 ft. 75 it. 4 1O' 30 SCH40 PVC
0 Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) 85 ft. 95 ft. 4 in. 30 SCH40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
_,______ ❑Irrigation _ 0__ fL _21- _ ft• _BentoniteChir_Pour_ -
Non-Water Supply Well: ft. ft.
❑Monitoring ['Recovery
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 21 ft. 95 ft: 1/4 x 1/8 Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft. 15 ft. Sand
9-18-2024 15 ft. 30 ft: Clay White
4.Date Well(s)Completed: Well ID# 30 ft. 60 tl. Sand Fine White
5a.Well Location: 60 ft. 95 fr. Clay White
Seth Warner 95 ft. ft. Rock
Facility/Owner Name Facility ID#(if applicable) ft ft.
180 St. Joseph's Road Southern Pines, NC 28387 ft. M
Physical Address,City,and Zip 21.REMARKS I ��-..�..•'it.....',. ./. CI k i
Moore 0
County Parcel Identification No.(PIN) O C T v L024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: lrrf:::r A`.t F' P-ri`r.4,-- 11j,1
(if well field,one lat/long is sufficient) [;rr;;ofr�C2
35.19778 N 79.37557 �, �, � 9-23-24
Sign,.re of Certified Well Contractor Date
-6 is`are-thewell s:-OPermanent--or-OTem ora 1
( ) O p rY By signing this fon'n7"hereby cefi hett`she wells)was were)constritcled7n aceordancF
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 ENo 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: 95 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 31 (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
Mud Rotary 24a 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 Center,Raleigh,NC 27699-1636
3 Pump 24c.For Water Supply&Injectil n;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: 10. well construction to the county 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