GW1-2021-04548_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Muneycuft 1R M WATER
�e � FRO To DEscRIPTTON
Well Contractor Name 268 n. 270 R' 2 gpm
4070-A nQ 2 g 2011 380 R 387 n 22 gpm
NC Well Contractor Certification Number N`?1 OUTER CASING for multi-cased wells OR LINER it a !feeble
OEcSCR� FRonI To DtAniE7 ER TffiCKNFSs rnIATERLu
Derry's Well Drilling, Inc. tro�pC° ,�;on 0 n 100 R 61/8 In SDR-21 PVC
Company Name i o 16.INNER CASING OR TUBING eotbermal closed-loop)
20-596 FROM TO DIAMETER►n• IH TCENTSS MATERIAL
2.Well Construction Permit#: [t• n•
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) n. n. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SITE Tt7ICKNESS MATERIAL.
n. n. In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n n• tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EnIPLACEMEN'f METHOD&AMOUNT
❑In•i ation 0 R• 3 R• Bent.Chips Gravity
Non-Water Supply Nell:
❑Monitoring ❑Recov 3 ft- 35 n Bt?ntonite Pumped
InJectlon Well: ft. n.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardnes soWrock tjpe,grain size etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 R 18 n Brown Dirt
4.Date Well(s)Completed: 12/1/20 Well ID# 18 n 400 R Slate
n. n.
5a.Well Location:
Amanda Stophel
Facility/Owner Name Facility iD#(if applicable) R. n Seams: 145',177-182',255',268'=8g,
416 E. Brief Rd., Monroe 28110
n. n. 380'=22g
Physical Address,City,and Zip 21.RE A LARKS
Union 08-180-002D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one Iaulong is sufficient)
N W
,�, 12/30/20
Signature of C ified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that Ibe wells)was 6vere)constructed in accordance
uvth JSA NCAC 02C.0100 or JSA NCAC 02C.0200 Well Constnction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo ropy of this record has been provided to the well owner.
If this is a repair,fill our known well constriction 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 to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-tearer supply wells ONLY with rho some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For mithiple ivells list all depths if dijjerent(example-3e?00'and 1@1001 construction to the following:
10.Static water level below top of casing: 12 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use +^ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (►n.) 24b.For Iniection Wells ONLY: h1i addition to sending the form to the address in
Rotary 24a above, also submit a copy of this jform 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
1
13a.Yield(gpm) 30 Method of test: 'Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Dlslnfectlon type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013