GW1-2022-04347_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
DWI ht L. Hunecutt a 14.WATER ZONES
y ,
g 7 FROM TO I DESCRIPTION
Well Contractor Name APR I 1 '192— 250 fit- 260 fit- 11 8 gpm
4070-A ft ft.
' m•. 11t,ii
NC Well Contractor Certification Number (3vtr+``%``'c^ �,^,1 j i). 15.OIITER CASING for multi cased wells OR LINER if a 7icable
i�^'i��'"' ^';�1l�•- FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. "1''"' '''(�r ft. fL in.
0 46 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermat dosed-loop)
10012186 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. in.
List all applicable well permits(ce.Coumy,State,Variance,Injection,etc.)
ft. & in.
3.Well Use(check well use): 19 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft in.
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft in
Olndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
: EMPLACEMENT 51ETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL rL tt
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG lattatch additional sheets if necema
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.haWness,soil/rocktyM grainsfi,ete
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 7 ft Fill Dirt
10/1/21 7 ft 14 ft. Brown Dirt
4.Date Wells)Completed: Well il)#
14 ft 27 ft Brown Rock
5a.well Location: 27 ft- 325 ft' Blue Granite
Valeria Serrano-Prado ft ft
Facility/Owner Name Facility ID#(if applicable)
15437 Romford PI, Charlotte, 28227 & fL Seams:50',58',72',95', 109', 113', 195',
fL ft 233',250'=8g
Physical Address,City.and Zip 21.RF.h1ARliS
Mecklenburg 139-341-27
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 t�G�Lt,[�. 10/28/21
Signature oolVertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this fo ni, I hereby certify that the,veil(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes Or ONO copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill our known well construction information and explain the nature ofthe
repair under r2I 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (fi.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifilo"erem(example-3@200'and 2 a 100) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rotary 24a above, also submit a copy of thin`firm 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
13a.Yield(gpm) 8 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: 112 lb. well construction to the county health'department of the courtly where
constructed.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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