GW1-2023-01669_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: II
John W. Hume cuff 14.WATER ZONES
I
Y FROM TO DESCRIPTION
Well Contractor Name 320 ft 325 fr 100 gpm
2465-A
NC Well Contractor Cer[ifiration Number FEB1 ;- 2i?23 15.OUTER CASING for multi cased wdls OR LINER ifa licable
Lit FROM TO DIAMETER I TBIC[QVESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 49 ft 6 1/8 i�"L I SDR-21 I PVC
tt�� Ct' r 16.INNER CASING OR TUBING(geothermal closed-loopi
Company Name Ar�t�nc:jgy FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 21-418 ft. ft. !to
List all applicable well permits(l.e.County,State,Variance,Injection,etc.)
ft. ft. ;id
3.Well Use(check well use): 17.SCREEN is
Water Supply Well: FROM TO DIAMETER 1.,SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public tL ft I
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft in
0Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
15ft-
TO MATERIAL• EMPLACEMENT METHOD&AMOUNT
[Irrigation 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring [:]Recovery 20 Bentonit9 Pumped
Injection Well: f.
❑Aquifer Recharge ❑Groundwater Remediation i GRAVEL PACK if applicable)
TO MATERIAL! EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. I,
❑Aquifer Test , ❑Stormwater Drainage
ft
❑Experimental Technology ❑Subsidence Control
ING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION(color,hardness,soiliroek a 'n sin etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 25 ft. Brown Dirt&Rock
4.Date Well(s)Completed: 9�1�22 Well ID# 325 It. Blue Rock
rt �5a.Well Location: ft.
Lifestyle Builders Inc. ft. ft:
Facility/Owner Name Facility ID#(if applicable) ?
ft. ft- Seams:56', 110', 115', 127',150',170', 187'
4711 Olive Branch Rd, Wingate 28174 ft. ,,. 210,274,310,315,,320-326=100gpm
Physical Address,City,and Zip 21.REMARKS
Union 09040019A
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) U
N wga& 9/15/22
SignaftWof Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
13y signing This form,I hereby certify that the tve!l(sJ 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 END copy ofthis record has been provided to the n ell,mvner.
If this is a repair,fill out known well construction information and explain the nature of the `
repair under#21 remarks section or air 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-svoter supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtjjerent(example-3@200 and 2@100) construction to the following:
I;
10.Static water level below top of rasing: 12 (ft.) Division of Water Resources,Information Processing Unit,
Ifsvater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Iniection,Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this I form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centei,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: Air
24c.For Water Supply&In_jection Wellsl:
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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013