GW1-2022-10081_Well Construction - GW1_20221107

l
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I I .
,
Dwight L. Hume cuff 14•WATER ZONES 'r
9 Y FROM TO DESCRIPTION I
Well Contractor Name >� 292 IL 296 " I I 1 gpm
4070-A ; E s, I\,1 sl-..D 535 fr- 540 It' 5 9pm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells'OR LINER it a Gcable
N O V 0 i7 822 FROM TO DNME.R I THICKNESS MATERIAL
Derry's Well Drilling, Inc. V V 1 ` 0 ft 46 ft- 61/8 I SDR-21 I PVC
Company Name ,.���fµ�.y , Un 16.INNER CASING OR TUBING eothermalclosed-loo
20-187 Dga,�rr3J FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable we((permits ll.e.County,State,Variance,Injection,etc.)
ft. ft. In
3.Well Use(check well use): 17.SCREEN
Water Supply Well:. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL f EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 3 Br Bent.Chips Gravity
Non-Water Supply Well:
3 tr' 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: % ft-
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licablc
FROM TO MATERIAL. 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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrack type,grain siu etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 7 ft Wet Brown Clay
4.Date Well(s)Completed: 4/15/22 Well ID# 7 ft- 27 ft. j; Brown Dirt
27 ft• 565 ft- �; Slate
5a.Well Location: ft. ft. I,
Scotty ClontZ fL ft
Facility/Owner Name Facility ID#(if applicable)
9326 Concord H Indian Trail 28079 tr. fr. Seams:93-97',99-104', 156', 193',250',
' ft. ft. 292'=1 g,413',510',515',535'=5g
Physical Address,City,and Zip 21•REMARKS
Union 08-180-002F
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one Wong is sufficient) •
N W yllallk" 5/5/22
Signature Well Contractor V, Date
6.Is(are)the well(i): 1OPermanent or ❑Temporary
By signing this forms,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: ❑Yes or ONo copy of this record has.beenprovided to the'well owner.
If this is a repair,fill out known well construction information and explain the nature of the ;
repair under#21 remarks section or on the back ofthisform. 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 ive!ls ONLY with tire same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3Q200'and 2Q100) construction to the following:
42 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft))
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: Inl'addition to sending the form to the address in
Rota 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: d
(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 276994636
13a.Yield(gpm) 6 Method of test: Air
24c.For Water Supply&Infection 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