GW1-2021-00819_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hume cuff 14.WATERZONES
g Y FROM TO DESt3tIP770N
Well Contractor Name 112 R' 120 fL 5 gpm
4070-A ft. f !
NC Well Contractor Certification Number 15.OUTER CASING for mnitFeased iv6lle`OR I INER ris litable
FROM - TO DIAMETER TffiQINEBS I MAT.
Derry's Well Drilling, Inc. 0 fL 165 R 61/8 in. SDR-21 I PVC
Company Nerve 16.FROM
CASING OR TUIIINGthermal dosed-too
o
20-617 a TEUCENESS MATEPJAL
2.well Construction Permit#: n
List all applicable well pennies(i.e.Coun(K State,Variance,Ir jection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO - WhMEM I SLOTS I7ffiCIdiFBS MATERIAL
ft.
❑Agricultural ❑ &Municipal/Public ft. in.
❑Creothermai(Heating/Coolmg Supply) 1DResidential Water Supply(single) ft. 1O
❑Industrial/Commcrcial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEI IENT METHOD a;AMOUNT
DIrrigation Non-Water Supply Well: 0 fL 3 fL Bent.Chips Gravity
❑Monitoring ❑teary 3 35 Bentonitt3 Pumped
Injection Well: ft.
❑Aquifer Recharge ❑GroundwaterRemediation '19.SAND/GRAYELPACK fifa - ble
❑Aquifer Storage and Recovery ❑Salinity Battier FROM ft. ft.TO MATEBIAL EMPIACnRNTM=IOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
-20.DRILLING LOG attach additional sheets R necessary)
❑Geothemlal(Closed Loop) ❑Tracer FROM TO DESC JMON color,hardness,wwroekmm own dm
etc
❑Geothermal Coolin Return ❑Other lain under#21 Remarks 0 fL 27 & Brown Dirt
4.Date Well(s)Completed: 9/17/21 Well lD# 27 fL 50 ft. Brown Rode
50 u. 265 fL Slate
Sa.Well Location: g, fL
Skip Thomas fa fL
Facility/Owner Name Facility ID#(if applicable)
& ft. ;Seams:70', 107',112'=5g
Hwy 218, Peachland 28133 ft. 1 ;
Physical Address,City,and Zip
21.REMARKS
Union 01038002D
County parcel Idemification No.(PIN)
5b.Latitude and Longitude in degceea/minates/seconds or decimal degrees: 22,Certification:
(if well field,one hat/long is sufficient)
I;r`
N w c� ' '10/14/21
Signature of0&tificd well Contractor Date
6.Is(are)the well(,): ®Permanent or ❑Temporary By signing this form,I hereby certify that;the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Contraction Standards and that a
7.Is this a repair to an existing well: ❑Yea or EINo 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 ofthe
repair under#21 remarks section or on the back of this forme 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, 265 (fY.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3@200'and 2@100) construction to the following:
41 Division of Water Resou6c,Information Unit,
10.3tatic water level below top of casing: (fL) Processing
!f water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: I 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: ry contraction to the following:
(Le.sugar,rotery,cable,direct push,etc.)
Division of water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
i
13a.Yield Wm) 5 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 Deparhnent of Environment and Natural Resources—Division of Water Res ources Revised August 2013
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