GW1-2022-10041_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:
John W. Hume Cutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name r ,• ®, 80 it. 87 'L ' ! 4gpm,
2465-A 'k, 215 ft. 220 rt. f 1 gpm
NC Well Contractor Certification Number NOV ► 7 2022 15.OUTER CASING for multi-cased wells OR I INEIt if a licahl
e
vY V FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. un o ft. 47 rt 61/8 ri SDR-21 PVC
Company Name lrtuf7;0'�,,"vir''T-2.Yt••� _
16:INNER CASING OR TUBING{eothermal closed-loon) _ .
21-436 u ` FROM TO M DL ETER ITO __ESS MATERIAL
2.Well Construction Permit#: ft IL ;;in:
List all applicable well permits(1 e.Coun%State,Variance,Injection,etc.)
ft. ft.
3.Well Use(check well use):
17.SCREEN_
Water Supply Well: FROM TO DIAMETER ''SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft• in. !•
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in.
❑IndustriaUCommercial ❑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 a licable
- TERIAL
❑Aquifer Storage and Recovery ❑ FROM TO MA EMPLACEMENT METHODSalinity Barrier ,
ft. fr. i,
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
' 20.DRILLING LOG'attach additional.sheets if necessa"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock bTe,gr2in sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft- 30 ft. Brown Dirt&Rock
4.Date Well(s)Completed: 5/13/22 Well ID# 30 It'. 305 fL �! Slate
ft. ft.
5a.Well Location: ft ft.
Ronny Chapman ft. fL
Facility/Owner Name Facility ID0(if applicable) gp
ft. ft. Seams:.55',60%80'=4 m,96,' 108', 115',
208 Chaney Rd., Monroe ft, ft.. 127', 1313', 155', 160', 171',215'=1gpm,295'
Physical Address,Ciry,and Zip .21.REMARKS ."..
,Union 08-204-019
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc Cation: �/�
w
"" ' ��� 7/21/22
N
Sigma a of Certified Well Contractor V, Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby terrify that[lie ivell(s)was(were)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 ❑No copy ofthis record has been provided to the well owner.
I
IJthis is a repair,fill out known well construction information and explain time nature ofthe '
repair under 421 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page tof provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach'additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ijdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,information Processing Unit,
IJivater level is above casing,use"+^ 1617 Mail Service Ceuteri'Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 241b.For Infection Wells ONLY: Inl 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.anger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center i Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form iv*thin 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county healtli department of the county where
constructed.
Form GW 1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013