GW1-2021-00830_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:
Dwi ht L. Hune cuff 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name 172 ft. 180 ft. 35 gpm
4070-A ft ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licahte
FROM TO DIAMETER THICt4VESS MATERIAL
Derry's Well Drilling, Inc. o ft 57 ft s 1/8 '- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-83 FROM TO DIAMETER THICIGiESS MATERIAL
2.Well Construction Permit#: ft. ft In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft, ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bTi ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite' Pumped
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL I EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑StormwaterDrainage it
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional sheets if oecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardy soi0mck CyM gmin she,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 19 R. Brown Dirt
4.Date Well(s)Completed: 10/8/21 Well ID# 19 ft 35 ft Brown Rock
35 ft- 185 ft Slate
5a.Well Location: fr. ft
Chase Benton & &
Facility/Owner Name Facility ID#(ifapplicable)
6404 Old Kennedy Ford Rd., Marshville 28103 ft. ft Seams:69',75',�1'�0;11T;'12fi', 135 1'67',
Y ft. ft. 17 _ g
Physical Address,City,and Zip 21.REMARKS
Union 01057004D
County Parcel Identification No.(PIN) i,i i c.i:f t•i c..'.':
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tatllong is sufficient) /
N W 1pu -101 [1 � l� 11/1/21
Signature of-Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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#21 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (tt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 16 (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 (in.) 24b.For Iniection 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 IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013