GW1-2021-04541_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonn can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune curt 14.WATER 7.0NES
Y FROM TO DESCRIPTION ,
Well Contractor Name 219 fL 223 R• 2 9pm
4070-A
NC Well Contractor Certification Number Lo11 15.OUTER CASING for multl-cased wells OR LINER f a Ilcable
L FROM TO Dt. *I" THICKNESS MATERIAL
Derry's Well Drilling_ , Inc. ,,�� 2 9 vq&k n- 55 n 6 1/8 i SDR-21 I PVC
Company Name .�f �gSS 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#.- 20-589 st•tiC'r3�t0�R Sg03�0� FROMn TO R DIA11�rER In. . THICKNESS MATERIAL
List all applicable evil permits(i.e.County,State,Variance,Tnjection,et
n. n. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n• R• in.
❑Geothetn al(Heating/Cooling Supply) ®Residential Water Supply(single) n n• In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01tri ation Q n. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 n• 35 n• Bentonitel Pumped
Infection Well:
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[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK f applicable)
FROM TO MATERIAL EMPLACEI1tENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n•
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothemtal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sail/rock a In sire etc.
❑Geothermal(Heating/CoolingReturn ❑Other lain under#21 Remarks Q R 27 ft.
Brown Dirt
n n Brown Rock
4.Date Well(s)Completed: 12/1 Q/2A 27 45
Well ID#
45 n 245 n Slate
5a.Well Location:
Nicholas Bolmon
Facility/Owner Name Facility iD#(if opplicAble) n• n. Seams:70', 11 O',219'=2g
7310 Medlin Rd.,Monroe 28112(Medlin Farms, Ph1, Lt33)
Physical Address,City,And Zip 21.REMARKS
Union 03159073
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)
N W ff�Y 1/26/21
Signature oftenified Well Contractor Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary By signing this form,I hereby certify that the,vell(s)was(were)constructed in accordance
Wth 1 SA 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 R]No copy of this record has been provided to rite;veil owner.
Ifthis is a repair,fill out knonn well construction information and explain ilia 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 pag6s ifnecessary.
For multiple injection or non-tvoter supply wells ONLY with the same construction,your can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection 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
12.Well construction method: Rotary 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
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13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form OW-I North Caroline Department of Environment And Natural Resources-Division of Water Resolvices Revised August 2013
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