GW1-2021-05836_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Hune cuff � 1 " 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name O 20�1 150 h' 160 fr. 20 gpm
4070-A JUL 1 ft. ft.
NC Well Contractor Certification Number r][©C8'S$1(tg U f11t 15,OUTER CASING for meld-rased wells OR LINER if a livable
Derry's Well Drilling, Inc. Irl11"m3tean 1ptJg"t'0I1 FROM f[• TO ft
DIAMETER In. THICKNFSS 11fATERIAL
cry gr p%,4R 0 115 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
21-50 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. DIAMETER
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL R. in. ,
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑Municipal/Public
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL to
❑industrial/Commercial ❑Residential Water Supply(shared) 19•GROUT
FROM TO M1IATERtAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 fL Bentonife Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT
[t. 2
❑Aquifer Test ❑Stormwater Drainage
tr, ft. ,
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if neceMary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,sail/roek CyM grain AM,eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 fL 25 fL Red Clay
4.Date Well(s)Completed: 4/12/21 sell iD# 25 fL 88 fL Brown Clay
88 fL 105 ft• Brown Granite
Sa.well Location: 105 fL 185 f• Blue Granite
William Nolan fL ft.
Facility/Owner Name Facility iM(if applicable)
1408 Antioch Church Rd.,Weddington(Providence Place U9) tL fL Seams:120', 138', 150'=20g
fL fL
Physical Address,City.and Zip 21.REMARKS_
Union 04072015H
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field one lat/long is sufficient) q�
N W ' "lejl - 5/1/21
Signature ofCerti ied Well Contractor Date
6.is(are)the well(S): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A N(.'AC 02C.0200 Well Construction Standards and that a
7.1S this a repair to an existing well: ❑Yes or ❑No 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:%11 remarks section or on the back of this forme 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.
Par multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INST'UC IONS
9.Total well depth below land surface: 445 (ft.) 24a. For Ali Wells: Submit this form within 30 days of complexion of well
tar multiple wells list all depths ifdifferent(example-3@200'and 2 rt 100) construction to the following:
10,Static water level below top of casing: 38 (R,) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I ;
11.Borehole diameter: 6 (in.) 24b.For injection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, 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.) I
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&injection]Veils:
13a.]'field(gpm) 2 Method of test: Air Also submit one copy of this foram within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county heitth department of the county where
constructed.
Farm OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources i Revised August 2013
I �