GW1-2021-00818_Well Construction - GW1_20211208

4
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.John W. Hune cutt FROM ER ZONES t
Y FROM TO I DESCRIPTION
Well Contractor Name 115 ft. 120 f`' 10 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 47 ft- 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-191 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft• 1°'
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
tL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
125ft-
TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑lrfi ation 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 35 IL Bentonite Pumped
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation GRAVEL PACK if applicable)
FROMTO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage
ft
❑Experimental Technology ❑Subsidence Control
ING LOG attach additional streets if nerxssa
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness soil/rock in siz eta
❑Geothermal(Heating/Cooling Retum ❑Other(explain under#21 Remarks 14 ft. Brown Dirt
4.Date Well(s)Completed: 8/10/21 Well ID# 25 ft' Brown Rock
265 ft- Blue Rock
5a.Well Location: ft.
Harry Steele ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
1131 Jamestowne Dr., Monroe 28110(Shirley Lots 11&12) ft.
65',75',85', 9:7 115'=10g,
. to 1,35',250',265'=10
Physical Address,City,and Zip 21.REMARKS
Union 09259003M
County Parcel Identification No.(PIN) ULU021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W � Gf/. :� ..• , ,8/31121 (lri i
Sign re of Certified Well Contractor Date
6.Is(are)the well(s): LaPermanent or ❑Temporary By signing this form,1 hereby certify that the rvell(s),vas(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction 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 well owner.
Ifthis 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 or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (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: 36 (ft) Division of Water Resources,Information Processing Unit,
If enter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 (in.) 24b.For Infection 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 276994636
13a.Yield(gpm) 10 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 Ili• 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