GW1-2023-02659_Well Construction - GW1_20230411

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.WATERZONES 1
g Y FROM TO DESCRIPTION
Well Contractor Name 157 it 161 3 gpm
4070-A _. w; .L _, '�n 415 fL 418 ft. 1 gpm
NC Well Contractor Certification Number APR i 20 ry� 15.OUTER CASING far multi-cased wells OR l 1NER if a licablc
t `'L FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. r__ o ft• 51 ft 6 1/8 SDR 21 PVC
Company Name �t ? %'•)i:f:i 16.iNNER CASING ORTUHING(eathezmal closed-loo )
21-383 ' FROM To DWEETER TMCKNESS MATERIAL
2.Well Construction Permit#: it it ;n.
lint all applicable well permits(J.e.County.State,Variance,Injection,etc.)
ft.
3.Well Use(check well use): 17.SCREEN -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft
❑Agricultural ❑Municipal/Public ft is
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. &
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERW. EMPLACErsENTMETHOD
R
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING I.oG(attach additional sheets itnecess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness•soRfmclity1we,grain sim efo)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft. Red Dirt
2/9/23 11 ft- 25 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
25 ft. 465 ft. Slate
5a.Well Location: ft. ft
Emerald Pointe Realty & fL ,
Seams:62',75,96', 110,157-161'=39pm,
Facility/Owner Name Facility ID9(ifapplicable) ft & 212%250',273',415'=1gpm
7835 Maigler Gin Rd., Monroe 28110 (Lot 1) ft. D.
Physical Address,City,and Zip 21.REMARKS
Union 08-039-012D
County Parcel Tdentification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient) e
N W �/ 2/14/23
Signature of Ccttified Well Contractor Date
6.Is(are)the well(s): 21Permanent or ❑Temporary By signing ibis form.I hereby certify thal lite evell(s)Ivan(here)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: ❑Yes or BNo. copy ofthis record has been provided to the ivell owner.
Ifihis is a repair,fill out latown well construction information and explain the nature ofthe
repair under t2l remarks section or air the back ofthisform. 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.
ror multiple injection or non-water supply wells ONLY with the same caustructiom you can
submit one form. SUBMITTAL INSTUCTiONS
9.Total well depth below land surface: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Tor multiple wells list all depths ifdifferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For lniection 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:
(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
13a.Yield m 4 Method of test: Air 24a For Water Supply&Injection Wells:
(gpm) Also submit one copy of this form within 30 days ofcompletion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013