GW1-2022-04294_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Cutt 14.WATER ZONES
John W. Hune _
Y FROM TO DESCRIPTION
Well Contractor Name — 219 f` 225 ft• 4 gpm
2465-A {^ n
NC Well Contractor Certification Number APR 1!7.� 15.OUTER CASING for multicased Rells OR LINER if a licable
FROM TO DIAMETER TffiCRNESS 1ATERIAL
Derry's Well Drilling, Inc. 0 fL 45 ft- 6 1/8 " 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TLBING(geothermal closed-too .
21-174�
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: W-" " ' -," & ft. in.
List all applicable well permits(i.e.Cam(v,State,I7irianee,liyeclion,etc)
ft. fL in.
3.Well Use(check well use): -17.SCREEN .. °r
Water Supply Well: FROM TO DIAMFW-R SIATSIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM .110 MATERIAL EMPLACEMEN'1'M!1'HOD&AMOUNT
❑TITi ation 0 fL 3 tL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable _
❑Aquifer Storage and Recovery- ❑Salinity Barrier FROM ft. ft. ER To ALATIAL EMPLACEMENT MMOn
❑.Aquifer Test ❑Stormwater Drainage
EL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necesss •
❑Geothenmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soil/rock type.gnin size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 8 ft' Red Clay
4.Date Well(s)Completed: 11/3/21 8 fL 19 ft. Brown Dirt
«'en m#
19 ft- 32 ft. Brown Rock
5a.Well Location:
32 ft• 285 ft Slate
Ronnie Laney ft. tL
Facility/OwncrName Facility lD=(ifapplicable) ft fL
Seams:65',74', 130', 165', 197',
Pigg-Mattox Rd., Monroe 28112 (Lot 2)
ft. ft. 219'=4g
Physical Address.City,and 7ip 21.REMARKS
Union 04-072-015F
County Parcel Identification No.(PRT)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W � 11/25/21
Si Lure of Certified Well Contractov Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this/i,rm,I hereby cerlifv that the well(.0 was/were)consiruc'led in accordance
with 15A!('AC 02C.(U00 or 15A AVAC'02C.0200 Well Construction Stattdords and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy nfthirs hoard has been provided to the xell ou ner.
lflhis is a repair.III out known well construction mfnrmalion and caplain the tramre(jthe
repair under-21 remarks section or an the hack of this faun. 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 muhiple iniection or nan-a ater supply wells OAZY n•tth the sine constmcrlon.you can
submil one form. SUBAITTT.AL INSTITCTTONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mothiple wells list all depths ifdtfferent(example-30,200'and 2@100') construction to the following:
IU.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above easing,use'-" 1617 Mail Service Center,Raleigh,NC 276994 617
I
II.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 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forth within 30 days of completion of
136.Disinfection type: Granular Amount 1/2 Ib. 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 R I e sources Revised August 2013
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