GW1-2022-04355_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form on be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCREMON
Dwi ght L. Huns cuff r,—)T7 r,
Well Contractor Name 240 fL 250 'L 8 gpm
4070-A 1 2022 ft. ft.
15.OUTER CASING for multi-cased wells) R fffapj=F
NC Well Contractor Certification Number FROM To DIAMETER T= S WE
0 7�Derry's Well Drilling, Inc. ft. 99 ft.0 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL2021-00002059
2.Well Construction Permit#: ft. ft. W.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. UL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
oAgncultural DMunicipalftblic ft. ft. in.
[]Geothermal(Heating/Cooling Supply) 011csidential Water Supply(single) ft• ft.
olndustrial/Commercial oResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
oftTigation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring DRecovery 3 ft- 20 fL Bentonite Pumped
Injection Well: ft. ft.
CAquifer Recharge OGToundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERMLL EMPLACEMENT METHOD
0Aquifer Storage and Recovery OSWinityBarrier ft. ft.
0Aquiler Test 0 Stormwater Drainage ft. ft.
oExperimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hodriess,saittrack"p,gmin size,etc.)
DGcothermal(Hcating/Cooling Return) 00ther(explain under#21 Remarks) 0 fL 42 ft. Brown Dirt
4.Date Well(s)Completed: 11/23/21 Well ID# 42 ft- 55 ft. Soft Brown Rock
55 'L 345 ft- Hard Brown Rock
5a.Well Location: ft. ft.
James Crowder ft. ft.
Facility/Owner Name Facility D:)#(if applicable) ft. ft. Seams: 115', 130', 148', 163',218',
1677 Summey Town Rd., Trinity 27370 ft. ft. 240-250'=8g
Physical Address,City,and Zip 21.REMARKS
Randolph 6791538733
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)N W 1/20/22
Signat=of Certified Well Contractor Date
6.Is(are)the wcll(s): 121Permanent or OTcmporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or ElNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 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
5
9.Total well depth below land surface: 'AA'— --- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 56 (ft.) Division of Water Resources,Information Processing Unit,
If water level 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
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(gp-) 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: 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
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