GW1-2022-10168_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hune cuff 14.WATER ZONES
5
Y OM TO DESCRIPTION
Well Contractor Name 69 h' 275 ft 30 gpm
4070-A NOV 1 0 2022 It. It. '
I5.OUTER CASING for multi eased wells OR LINER if a licahle
NC Well Contractor Certification Number FROM TO DIAMETER i THIC[�iESS MATERIAL
Derry's Well Drilling, Inc. (nkofin"o.)Perm" � ft. 45 IL 61/8 1- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2021000012 FROM TO DIAMETER! THICKNESS MATERIAL
2.Well Construction Permit#: ft R• in.
List all applicable well permits(1.e.County.Slate,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 im
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 rL 35 ItoBentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft h'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft
❑Aquifer Test ❑Stormwater Drainage
ft ft,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiBrock etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft 12 ft Red Dirt
12/29/21 12 'L 22 It. Brown Dirt
4.Date Weil(s)Completed: Well ID#
22 ft 345 & Slate
5a.Well Location: g• ft,
Eric Carroll ft. ft
Facility/Owner Name Facility ID#(if applicable)
ft 'L Seams: 95', 107', 130', 158', 192',
1686 Skeen Rd., Denton 27239 it ft
248-252',269'=30g
Physical Address,City,and Zip 21.REMARKS
Davidson
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwcll field,one lat/long is sufficient)
N W , 1/15/22
Signature ofC66nified Well Contractor Date
6.Is(are)the well(s): G51ermanent 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.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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#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 INSTUCPIONS
9.Total wel depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdijferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing:
9 Division of Water Resources,Information Processing Unit,if (ft.)water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
V
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In laddition 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) 30 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 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 Resources Revised August 2013