GW1-2021-01778_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fortn can be used for single or multiple wells
1.Well Contractor Information:
John W. Mune`cuff 14.WATER ZONES
7 FROM TO DESCRIPTION 1
Well Contractor Name 100 n• 110 n ! 115gpm
2465-A ws'c ')I � n. n.
NC Well Contractor Certification Number �_ `` 15.OUTER CASING for multi creed Hells OR LINER if o licable
v OM TO DIAMETER TIHCKNESS MATERIAL
Derry's Well Drilling, Inc. Qe �Sg�n9 0 n• 91 n• 6 1/8 i" SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eother al closed400
10Q114Q9MfO 30 Se FROM TO DIAMETER 7MCAT'ESS MATERIAL
2.Well Construction Permit#:
List all applicable well pennits(i.e.County,State,Variance,Injection,ate.)
tt. tt. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n. n• in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n. n• In.
❑Industrial/Commereial ❑Residential Water Supply(shamd) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
131nigatin
0 n' 3 n. Bent.Chips Gravity
n-Wa Supply Well:
❑Monitoring ORecovery 3 n• 35 n• Bentonite Pumped
Injection Well: n• n•
❑Aquifer Recharge ❑Grotmdwater Remcdiation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Dminage
R. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes soillrock type,grain size etc
❑Geothermal (Heating/Cooling Return ❑Outer(explain under#21 Remarks 0 n. 16 n. Red Dirt
$/6/20 16 n• 32 n• Brown Dirt
4.Date Well(s)Completed: Well ID#
32 n 55 n• Brown Rack
Sn.Well Location:
Christopher M. Croxton 55 �: eo Unconsolidated Rack
80 165 Blue Rock
Facility/Owner Name Facility ID#(if applicable)
9619 Alexis Dr., Charlotte 26227 n' n' Seams: 100'=15g, 145'
Physical Address,City,and Zip 21.REDIARKS
Mecklenburg 192-0$5-13
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W 8/31/20
Sig,06 of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that fire well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.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 the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#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 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 walls ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter- 6 (In.) 24b.For Iniecdon WeOs 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: Rory construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
138.Yield(gpm) 15 Method of test: Air 24c.For Water Supply&Iniection[Wells: j
Also subunit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount 1/2 Ib. well construction to the county health[department of the county where
constructed.
Fonn OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Reiso i es Revised August 2013
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