GW1-2023-01633_Well Construction - GW1_20230214

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwi ht L. Hume cuff 14.WATERZONES'.,
g Y FROM TO DESCRIPTION
Well Contactor Name 390 f t. 395 H' 79pm
4070-A FEBft &NCWe1lContractorCertificationNumber E 1 Z�23 15.OUTEWCA5ING formulti-casedvv ARLINER ifs licahle
FROM TO DIAMETER I� TmCIQiFSS MATERIAL
Derry's Well Drilling, Inc. In�rinn- on?rx �tsu-;��f t t ,� 0 ft. 45 ft 61/8 1t' SDR-21 PVC
T ,
Company Name t✓� �,;;i, ,�c 16.INNER CASING ORJUBING eothcrmal closed-loop) '
22-239 FROM TO DIAMETER I THICIINFSS MATERIAL
2.Well Construction Permit#: ft. fL in.
List all applicable well permits(i.a County,SNie,Variance,Injection,eta)
ft. it. is
3.Well Use(check well use): -17.SCREEN "
Water Supply Well: FROM To DIAMETER SLOT SIZE THICICiESS MATERIAL'
❑Agricultural ❑Municipal/Public ft. ftis
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) -1:3:GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
olrri ation 0 ft' 3 fL 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 'f a licable
FROM TO MATERIAL + EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harda soil/Lock tip., etc.
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks 0 ft- 17 ft. Brown Dirt
9/8/22 17 fL 400 ft- Slate
4.Date Well(s)Completed: Well M# fL ft.
sl
5R.Well Location: ft. ft. I,
Jeffrey W. Linson ft. ft.
Facility/Owner Name Facility ID#(if applicable)
9715 Running Cedar Ln,Indian Trail 28079(Tallwood Est.,Lot 5) ft. Seams:52',60',92', 171',274',390'=7gpm
it. ft.
Physical Address,City,and Zip 21.REb1ARKS' '
Union '08210016
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient) }-
N W �7 L. r IGUZO'c/ 10/1/22
Signal=o Certified Well Contractor Date
6.1s(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)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 ONo copy of this 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 farm. 23.Site diagram or additional well details:
You may use the back of this page to piovide 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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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 ifdifferem(example-3@200 and 2@100) construction to the following: I
10.Static water level below top of casing: 42 A) 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 injection Wells ONLY: In alddition to sending the form to the address in
Rotary. 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 276991636
13a.Yield(gpm) 7 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 OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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