GW1-2021-01649_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells p
1.Well Contractor Information: 9E
DWIDwight L. Hume cuff 14.WATER ZONES
9 Y FROM TO I DESCRIPTION
Well Conn-actor Name 105 e• 115 12 gpm
4070-A tt. ft. i
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NC Well Contractor Certification Number 9 20�• 15.OUTER CASING for milli cased wells)OR LINER if applicable)
Y!( �• FROM TO DIAMETER THICKNESSI MATERIAL
Derry's Well Drilling, Inc. rpsilraVnW 0 ft. 47 it- 61/8 in SDR-21 I Pvc
Company Name ��DD R _.h'10n 16.INNER CASING OR TUBING(geothermal closed-loop)
20190�BU 7 Dw �` FROM TO DL4MTER TMCIGN'ESS MATExrer.
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
ft. ft. in.
❑Agricultural ❑MumcipaMblic
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. it. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EDIPLACEMENT METHOD&AMOUNT
01ni ation 0 rt• 3 r<• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 35 ft• Bentonite Pumped
Injection Well: rl' tt j
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL. EMPLACE M ENr METHOD
❑Aquifer Storage and Recovery El Salinity Barriertt. ft.
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional(sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,will k type,grain size etc.
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) 0 rt. 13 ft. Brown Dirt Rock
12/8/20 13 f` 185 ft- Slate
4.Date Weil(s)Completed: Well ID# B tt
5a.Well Location: ft. ft
Mark Bowers(Ralph Adams)
Facility/Owner Name Facility ID#(if applicable)
e. n• !Seams: 71',88', 105'=12g
300 Peacekeepers Way, Lexington 27292 tt•
Physical Address,City,and Zip 21 REMARKS
Davidson
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N W Z�>W4&�,L., Wa 12/30/20
Signature of Cet'led Well Contractor IDate
6.Is(are)the weil(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that ithe ive//(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the,yell 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 at,non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 185 (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: (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: hi addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 12 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: 1/2 lb.Granular well construction to the county health department of the county where
constructed.
Forin GW-1 North Carolina Department of Envircinmeut and Natural Resources-Division of Water Res i ources Revised August 2013