GW1-2023-02554_Well Construction - GW1_20230410

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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:
John W. Hune cuff 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 110 ft 117 ft 1 2 gpm
2465-A 261 f4 1270 ft 1 8 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased welts OR LINER if a livable
FROM TO DIAMETER THICIfl. MATERIAL
Derry's Well Drilling, Inc. 0 ft 102 ir• 61/8 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-90 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft & in
List all applicable well permits(i.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 in
❑Agricultural ❑MunicipaMblic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in
❑hldustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 M 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 1'a livable
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 necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness saiVrack lype in sine,etc.)
❑Geothermal eating/CoolingReturn) ❑Other(explain under#21 Remarks 0 ft- 60 ft Brown Dirt
4.Date Well(s)Completed: 6/6/22 Well ID# 60 ft 95 ft Brown Dirt&Junky Rock
95 ft 285 r' Blue Rock
So.Well Location: ft. ft.
Badley S. Hammill fur ft
Facility/Owner Name Facility lD#(if applicable) ft ft .__ -Seams•110-117'=2gpm, 151', 197',
7723 Gold Hill Rd, Rockwell 28138 ft ft. '2s '=s m
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Physical Address,City,and Zip 21.REMARKS
Cabarrus APR 1 U 2023
County Parcel Identification No.(PIN) ^^ n ^^
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: d 7Glt��j7v[1- 3 � J
(ifwell field,one fat/long is sufficient)
N W g�� w• ' ! 6/30/22
Sign We of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form.I hereby certify that the well(s)was liver¢)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200{Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has beery provided to lite 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 of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 tr
construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply spells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface' 285 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple spells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of using: 36 (it.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter• 6 (in.) 24b.For Injection Wells ONLY: In addition 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: ry 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 Marl Service Center,Raleigh,NC 276994636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 1 Method of test: Air 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
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