GW1-2021-00810_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
cutt 14.WATER ZONES
John W. Hune
Y FROM TO DESCRIPTION
Well Contractor Name 126 R' 135 R' 6 gpm
2465-A 200 it• 210 R• 9 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER tf a licable
FROM TO DIAMETER THICIQVESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 55 IL 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
21-178 ESCREEN
TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i°•List all applicable wellpermits(i.e.County,State,Variance,Injection,etc.) ia.
3.Well Use(check well use):
Water Supply Well: To DIAMETER SLOTSIZE THICKNESS MATERIAL
fL❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 it• 3 IL Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 IL Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: fL R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO I MATERMLL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness soil/rock tym goin ske,etc
❑Geothermal(Heating/Cooling Return) ❑Other ex lain under#21 Remarks 0 R. 19 ft. Brown Dirt
4.Date Well(s)Completed: 8/9/21 Well ID# 19 R• 30 ft. Brown Rock
30 R• 225 ft- Slate
59.Well Location: ft. ft,
Richard Webb f. ft.
Facility/Owner Name Facility ID#(if applicable)
R. fa Seams: 76'126'=6g, 175',200'=9g
Sincerity Rd., Monroe 28110 ft. R.
Physical Address,City,and Zip 21.REMARKS
Union 08075003D t
County Parcel Identification No.(PIN) DEC S 2021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient) � � � .t
N W 8/31/21
Si re of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the uvil(s)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or I SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy ofthis 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 ofthis 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-wafer supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (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(a)100D construction t0 the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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
13a.Yield(gpm) 15 Method of test: Air 24c.For Water Supply&Injection 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i