GW1-2022-10046_Well Construction - GW1_20221107

I
WELL CONSTRUCTION RECORD
For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information.
Dwight L. H une cuff 14.WATER ZONES
Y FROM TO DESCRIPTION i
Well Contractor Name •i j 9 i -,1 389 tt' 400 M I 1 gpm
4070-A � -
NC Well Contractor Certification Number NOV r( n77 15.OUTER CASING for multi cased wells 9R LINER if a livable
hJ i FROM TO DIAMETERi I 'TRICRNESS MATERIAL
Derry's Well Drilling, Inc. 0 1t. 46 ft- 61/8 ji"; SDR-21 PVC
Company Name �{iyGCv(e - '�" ❑ 16.INNER CASING OR TUBING eothermal closed-loo
21-435 '�!�{Q: �tV FROM TO DIAMETEW THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ;in.
List all applicable ivell permits(i.e.County,State,Variance,Injection,eta)
iG ft. lin.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 23Residential Water Supply(single) R• ft. in.
❑Itidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft• Bent.Chips, Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. fL-
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK: if applicable)
.
❑Aquifer Storage and Recovery ❑ FROM TO Salinity Barrier ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM . TO DESCRIPTION color,hardness,soil/rock in size,etc.
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 16 ft. Brown Dirt/Rock
4.Date Well(s)Completed: 5/17/22 Well ID# 16 tt 545 tt i,' Slate
ft. fL Ij
5a.Well Location: ft. ft. I
Jessie Northcutt
rr. ft.
Facility/Owner Name Facility ID#(if applicable)
5322 Olive Branch Rd., Wingate 28174 ft rt Seams: ,129', 135', 150',312',389'=19,
g ft. rt. 415',438'
Physical Address,City,and Zip 21.REMARKS
Union 09-006-011 B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient) / q
N W 7nSr/ 614/22
Signature of Cued Well Contractor f Date
I.
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 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or ONO copy ofthis record has been provided to lhe4rell owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe I.
repair under 421 remarks section or,on the back of this fonn. 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with tire same construction,you can
submit one form. SUBIIIITTAL INSTUCTIONS
9.Total well depth below land surface: 545 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3@200'and 2@100) construction to the following: I',
10,Static water level below top of casing:'74 (ft.) Division of Water Resources,information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center"r Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Lnieetion Wells ONLY: in addition to sending the form to the address in
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: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Upderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 1 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form Pwithin 30 days ot'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 Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I
I