GW1-2021-00746_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwi ht L. Hunet/cuff 14.WATER ZONES
9 J FROM TO DESCRIPTION
Well Contractor Name 133 e. 140 fL 12 gpm
4070-A ft. I f1.
NC Well Contractor Certification Number 15.OUTER CASING for multl-cased wells OR LINER if s licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft, 100 e 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
10011807 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fL ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft f4 iu
n.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic fL ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,saiVrodc type,grAn shy,eta
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 21 ft. Red Clay
4.Date Well(s)Completed: 4/8/21 Well ID# 21 ft 57 tl. Brown Clay
57 r' 82 ft. Brown Granite
5a.Well Location: 82 f 185 e' Blue Granite
Summit Building Group, LLC & ft
Facility/Owner Name Facility ID#(ifapplicable) s ; a
ft. fr. Seams: 106', 114" 133`=12g t
8825 Vagabond Rd., Charlotte 28227 ft ft. 8
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 139-271-71
County Parcel Identification No.(PIN) i;i'_—t"'"'1i7"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W TAG Lt.L. GULQl1f'.LCt 4/30/21
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy ofthis 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 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 wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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 1@100') construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Iniection Wells ONLY: ln'addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
It 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
13a.Yield(gpm) 12 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 department of the county where
constructed-
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013