GW1-2023-01420_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD `
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Hume cuff .14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name _ _ 182 ft. 187 ft. f ; 25gpm
4070-A � .. s' 4 ''._. ft. ft.
,r
NC Well Contractor Certification Number �'45.OUTER CASING for multi cssed.wells OR LINER if a livable
FEB 1) p 2023
n 2 3 FROM TO DIAMETER THICIINE53 MATERIAL
Derry's Well Drilling, Inc. ` 3 l' 0 ft' 198 ft• 6 1/8 'n• I SDR-21 PVC
Company Name Ini,;fYlr3Yl � s�rDG.3�a£:I,�Uml -16:INNER CASING ORTUBING eothermalclosed-loo
1 p—n�p ��#a� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: v L v % ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc..)
ft. 1t. � in. •
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. t "t
❑Industrial/Commercial ❑Rdsidential Water Supply(shared) 18.GROUT '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 3 ft• Bent.Chips Gravity
[]Monitoring ❑Recovery 3 ft- 20 ft• Bentoriite Pumped
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Rernaation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO" MATERIAL EMPLACEMENT METHOD
ft. ft. i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control'
-ZO.DRILLING LOG attach additional sheets if necessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hwilnns eoilfrock etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft, 45 ft- i Brown Sandy Dirt
4.Date Well(s)Completed: 2/15/22 well Dl# 45 ft- 62 ft. Wet Brown Dirt
62 ft• 71 ft. Junky Blue Rock
Sa.well Location: 71 ft- 200 ft Blue Granite
John Melton f. ft.
Facility/Owner Name Facility ID#(if applicable)
ft & Seams: 109-113', 118',133', 1.70',
10555 Crimson Way, Concord 28025 ft. ft. i 182-187'=25gpm
Physical Address,City,and Zip IL REMARKS
Cabarrus
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one Wong is sufficient)
N w 'L"' 3/10/22
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yea or FINo 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 of thisform. 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: 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: 200 14a. 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: 20 (R,) 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 Infection Wells ONLY: 1In,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: 1
(i.e.auger,rotary,cable,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) 25 Method of test• Air 24c,For Water Supply&Iniection`II
Wells:
Also submit one copy of this forrit 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.
I �
Form OW-1 North Carolina Department of Enviromnent and Natural Resources—Division of Water R trees Revised August 2013