GW1-2021-04510_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For internal Use ONLY: j
This Iona can be used for single or multiple wells
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1.Well Contractor Information:
Dwi ht L. Muneycuff 14.WATER ZONES
.7 7 FROM TO DESCRIPTION
Well Contractor Name "� 267 n 270 n ; 3 gpm
4020-A 021 409 n 415 n• R 7 gpm
NC Well Contractor Certification Number A P V 15.OUTER CASING for multi-cased wells OR LINER if n licable
F� FROM TO DLOIETER TffiCICIQESS MATERIAL
Derry's Well Drilling, inc. oce�$1ngU� 0 it. 50 n 6 1/8 I" SDR-21 I i'VC
Company Name ^I se�Jlvl 16.INNER CASING OR TUBING eotbermal closed-loo
Irti.. OWN FROM To DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 20-200 n. n In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
n. n. in.
3.Well Use(check well use): 19.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIQtESS MATERIAL
❑Agricultural ❑Municipal/Public n n• in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n n' In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 10.GROUT
FROM TO MATERIAL rAmACEmENT NixTHoD&AmouN r
❑hri ation 0 n• 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 n' 35 n Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL' EMPLACEMENT AIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock in sin etc.
❑Geothema!(Heating/CoolingReturn ❑Other(explain under#21 Remarks 0 n' 28 n Brown Dirt
12/1 S/20 28 n 41 n -Brown--Rock
4.Date Well(s)Completed: Well ID#
41 n 445 n Slate
So.Well Location:
Darrell Baucom
Facility/Owner Name Facility M#(if applicable)
n. n. Seams: 75', 130', 137', 173',267'=3g,
4021 billcrest Church Rd, Monroe 28110 320',409'=7g
Physical Address,City,and Zip 21.REMARKS
Union Part of 08-204-001
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 1/15/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constntcted in accordance
utith 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consmrction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has been provided to the'ivell owner.
If this is a repair,fill out knout well construction information and explain the nature of the
repair render#11 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
S.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: 44eJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdij)erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
ICJ 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: 6 (in.) 24b.For Inlection Wells ONLY: In,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.)
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) 10 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 deparunent of the county where
constructed.
Form OW-I North Carolina Department of Enviromnent and Nature I Resources-Division of Water Resources Revised August 2013