GW1-2022-10039_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD i
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
DwiDwight L. I lone cuff 14.WATERZONEs
9 Y FROM TO DESCRIPTION
Well Contractor Name 251 fL 256 ft I 49pm
o
g�.
4070-A a U E f `�,�.v�....,Il ft rr I
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells 0R LINER if a livable
p FROM TO DIAMETER t I THICKNESS MATERIAL
Derry's Well Drilling, Inc. NOV ! 202 0 ft. 46 ft 61/8 SDR-21 I PVC
Company Name InecNN3+tD',l Prmrz,r- g Unit 16.INNER CASING ORTUBING eothermalclosed400
22-178 D{:'JOBOG' FROM TO DIAMETERi, THICKNESS MATERAL
2.Well Construction Permit#: ft. fw in
List all applicable ivell permits(i.a County,State,Variance,Injection,etc.)
ft. ft. �•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DUMETER 1 SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL 1n. r
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL" EMPLACEMENT•METHOD&AMOUNT
[ZlIrri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
[]Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRTMON color,hardn soil/rock in size,etc
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 9 ft. I. Brown Dirt 8r Rock
9 ft 325 fL Slate
4.Date Wells)Completed: 5/20122 Well ID# ft ft
I.
5a.Well Location: t ft ft
Mark Driver A. ft.
Facility/Owner Name Facility ID#(if applicable)
5320 Sugar&Wine Rd., Monroe 28110 t�. sr. Seams:5s',ss',73',7T,92',98', 111', 150'
j: 193,251'=4gpm
Physical Address,City,and Zip 21.REMARKS
Union 01228016B
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) I
N . pr 6/4/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary `
By signing this jornr.I hereby certify Thar the.rvell(s)was(tivereJ constructed in accordance
with 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 ElNo copy ofthis record has been provided to the well owner.
Ijthis is a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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
I ,
9.Total well depth below land surface: 325 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdi,#erem(example-3@200 and 2@100� construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: IiI 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.) h
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 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. I
Form GW-1 North Carolina Department of Emironment and Natural Resources—Division of Water Resources Revised August 2013