GW1-2022-10019_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 4 '
cuff 14.WATERZONES
John W. HUne
Y FROM TO DESCRIPTION
Well Contractor Name r-- t pr* 390 ft. 396 ft' I I 1 gpm
NC Well Contractor Certification Number N O V 202L 15.OUTER CASING' for"multi-cased wells OR LINER if a licable
FROM TO DIAMETER; ! THIC[QHESS .MATERIAL
Derry's Well Drilling, Inc. o ft- 1101 ft- 6 1/8 !','n1 SDR-21 I PVC
Company Name In►tii FTi' D i •aw dti 16.INNER CASING OR TUBING(geothermal closed-lox
2022-0000067P"'016a'G FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ft ft.
List all applicable well permits(i.e.Coun(,State,Variance,hyection,etc.)
ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL
st n ;n.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft it hL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation . 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft- Bentonite� Pumped
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,grain sbre,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 20 fl. Red Dirt
4.Date Well(s)Completed: 6/14/22 well EN20 ft 90 ft Brown Dirt&Rock
90 It- 400 ft• Blue Granite
5a.Well Location: ft ft
Sandra Inman/Carolyn Hardister ft ft
Facility/Owner Name Facility M#(if applicable)
5691 Old Walker Mill Rd., Randleman 27317 & ft Seams': 11s', 140', 145',155', 175',216',
It. ft. 235',270',335',370%385',390'=1gpm
Physical Address,City,and Zip 21.RENIARKS
Randolph 7757951304
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i'
22.Certification:
(ifwell field,one lat/long is sufficient)
N W 7/14/22
Si of Certified Well Contractor Date
6.1s(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby.certify that�Ihe well(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofihis record has been provided to the well owner.
If this Is a repair,fill out knmvn 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-ivater supply ivells ONLY with the same construction,you can i;
submit one form. SUBMITTAL INSTUCTLONS I
il
9.Total well depth below land surface: 400 (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 2@100) construction to the following: j
10.Static water level below top of casing:
48 (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of";fort within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Untlergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 Method of test: Air Also submit one copy of this form within 30 days of completion of
136.Llisinfection`type Granular Amount 1/2 It). 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