GW1-2021-00839_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:
curt 14.WATER ZONES
John W. Hune
Y FROM TO I DESCRIPTION
Well Contractor Name 130 `t 135 `t' 1 gpm
2465-A
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER If a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 150 It 6 1/8 1O SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
21-170 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit IV: it. fL in.
List all applicable well permits(i.e.Coumy,State,Variance,Injection,etc) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) I231kesidentW Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 ft- Bentonite Pumped
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Batt FROM Barrier fL TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color hardness soil/rack tym Zrain sirA etc.
❑Geothermal(Heating/Cooling Return) ❑Otter(explain under#21 Remarks 0 fL 17 ft Brown Dirt
8/21/21 17 fL 30 fL Brown Rock
4.Date Well(s)Completed: Well ID#
30 it- 405 fL Blue Rock
59.Well Location: g• fL
Gala Homes& Properties ft iL
Facility/Owner Name Facility ID#(if applicable)
2326 Louanne Dr., Wingate 28174 Austin Hills Lt 40 fL ft' Seams:76',90',96', 130'=1g, 165',215',
9 � ) fL fL 225'236',330'
Physical Address,City,and Zip 21.REMARKS
Union 02199061 DEC0 21
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaVlong is sufficient)
N W 9%20/21
Sigr6fure of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)ivas(were)constructed in accordance
Ivith 1 SA NCAC 02C.0100 or 15A NCAC,02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well constniction information and explain the nature of the
repair tinder#21 remarb section or on the back of this form. 23.Site diagram or additional well,detaft
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 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
47 Division of Water Resources,Information Processing Unit,
(f
10.Static water level below top of casing: L)
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection 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) 1 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013