GW1-2021-00813_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:
cutt 14.WATER ZONES
John W. Hune
Y FROM TO I DESCRIPTION
Well Contractor Name 190 fL 195 It 2 gpm
2465-A f. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 iG 53 fA 16 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-171 FROM TO DIAMETER TmCKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
fL ft. in.
OAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) N ft 'n
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri ation 0 It. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it 35 It' Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R TO ft MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test OStonnwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardno soil/mit tnw,grain size,etc.
❑Geothermal (Heating/Cooling Return 001her lain under#21 Remarks 0 ft 19 fi Brown Dirt
4.Date Well(s)Completed: 8/24/21 Well ID# 19 ft' 35 ft• Brown Rock
35 ft 405 IL Blue Rock
59.Well Location: ft, ft.
Gala Homes & Properties ft. E,..
Facility/Owner Name Facility ID#(if applicable)
2330 Louanne Dr., Wingate 28174 (Austin Hills Lt 41) ft. f`' Seams:60',90',95, 'O '
ft. rL 190'=2 gpm
Physical Address,City,and Zip 21.REMARKS
Union 02199062 -
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) 904t,
N W 9/20/21
Sigh ure of Certified Well Contractor 'Date
6.Is(are)the well(s): (OPermanent or OTemporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 1 SA NCACs02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END 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 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (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 291001 construction to the following:
10.Static water level below top of casing: 47 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rota 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:
(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) 2 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: Amount: 1�2 II).
Granular well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water ReLurces Revised August 2013