GW1-2021-00828_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:
Dwl ht L. Hune`'cuff 14.WATER ZONES
g 7 FROM TO DESCRIPTION
Well Contractor Name 240 ft. 250 tt 100 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 46 ft 6 1/8 i i- I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-486 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.Coumy,State,Variance,Injection,etc.)
ft ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
tt ft in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) M ft. in.
❑Industrial(Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft. Bentonitel Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock q1w,Zrain si etc.)
[]Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 ft Brown Dirt Rock
4.Date Well(s)Completed: 9/27/21 Well ID# 6 ft 250 ft- Slate
ft. ft
5a.Well Location: ft. ft
Russell Fox fL ft
Facility/Owner Name Facility ID#(ifapplicable)
ft ft
Simpson Circle, Indian Trail 28079 (Lot 2) seamy 55� =2ao �oo9t
w ft.
Physical Address,City,and Zip
21.REMARKS V a— Zile
Union 09241031
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 t7�rfN;g�ct-,L . 7 ' 10/20/21
Signature orCertified Well Contractor Date
6.Is(are)the well(s): [OPermanent 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 15A NCAC 02C.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.
if this is a repair,fill out known well construction information and explain the nature of the
repair under 421 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
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 INSTUCPIONS
9.Total well depth below land surface: 250 (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: 14 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this forth 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
13s.Yield(gpm) 100 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-l North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013