GW1-2023-01426_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:
Der L. HUne cuff Y4•WATERZONES
Derry y FROM TO DESCRH'TION
ft'Well Contractor Name R.*- a 106 fL 108 j 1 gpm
2663-A e �- p 206 fL 210 fL: 4 9p►n
NC Well Contractor Certification Number FEBrI n�� 15.OUTER CASING for muI cased wells OR LINER if a NIIIe
E 0 8 Ll FROM TO DIAMETER ) TffiCffiVFS5 MATERIAL
Derry's Well Drilling, Inc. 0 fL 88 fL 61/8 I;a SDR-21 I PVC
Com mm Name ,l I�t C ''7` 16.INNER CASING OR TQBING eothermal closed-loop)
P Y iue"rYir311� 1�1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22 I �•u a� ft. fL i°
List all applicable well permits(i.'e.County,State,Variance,Injection,etc.)
ft. f4 , in.
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fL. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. iv
❑IndustriaUCommercial []Residential Residential Water Supply(shared) GROUT .
FROM TO MATERLIL r EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 fL 20 fL Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color,hardness soivrocmr sire,eta
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f, 10 ft. Red Dirt
9/15/22 10 fL 70 ft. Brown Dirt&Rock
4.Date Well(s)Completed: Well ID# 70 fL 305 ft' j Granite
5a.Well Location: fL ft.
Nolan.Richard fL fL
'Facility/Owner Name Facility ID#(if applicable)
1070 High Meadows, Concord 28025 fL Seams: 106'=1gpm, 116', 125', 155', 175',
9 tr. ft ;192',206'=49pm,230',268'
Physical Address,City,and Zip 21.REMARKS -
Cabarrus {
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification '
(ifwell field,one laHlong is sufficient) T 21 y j 1� ,;
9/30/22
N W Signature orf'Certified Well Contractor 1 Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby term that'the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of this record has been provided to thh�wM 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 this form. 23.Site diagram or additional well details:
You may use the back of this page tt 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 1
submit one form. SUBMITTAL INSTUCTIONS ?,
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example.3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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: �.
(Le.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
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13a.Yield(gpm) 5 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 Idepartment of the county where
constructed.
Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013
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