GW1-2023-02650_Well Construction - GW1_20230411

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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:
cuff 14.WATER ZONES
John W. Hume
Y FROM TO I DESCRIPTION
Well Contractor Name 210 ft• 215 ft• 2 gpm
2465-A t .-.. 338 ft- 342 ft- 1 gpm
NC Well Contractor Certification Number n p p 15.OUTER CASING for mu16 cased wells OR LINER if a licable
APR R I 1 2023 FROM TO DIAMETEn T1i11:[QIESS MATERIAL
Derry's Well Drilling, Inc. 0 f4 148 ft 61/8 1n SDR-21 I PVC
Company Name i l l'�''"'-'^ '.l "" :_" .r 16.INNER CASING OR TUBING eothcrmal closed-loo
P Y rv,g,:;-,•:• .�,., .:.'J i.a;.: FROM TO DIAMETER THICKNESS MATERIAL.
22-449 -' '
2.Well Construction Permit#: it ft. in.
List all applicable ivell permits C.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 ❑Municipal/Public ft
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) IL
'ft hL
❑Industrial/Conunercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irr; ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 sr. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft. MATERIALI EMPLACEMENT METHOD
❑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,soiurock type rain she,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 25 ft. Brown Dirt
2/15/23 25 ft- 365 fL Slate
4.Date Well(s)Completed: Well IIT#
ft. ft.
5a.Well Location: ft ft
Bonnie Helms
ft ft Seams:55',59',77',90',95-101', 121',
Facility/Owner Name Facility ID#(if applicable)
Bundy Williams Rd., Marshville 28103 & ft- 125', 130', 145', 150', 175', 190',210'=2g,
ft ft 230',240',250%265',285',307',338'=1g
Physical Address,City,and Zip 21 REMARKS
Union 01210009B (part off
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwetl field,one lat/long is sufficient) //
N W �& !�i/. I)IU 3/8/23
SignaWofCerfified Well Contractor Date
6.Is(are)the well(s): 1211'ermanent or ❑Temporary Ly signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IJNo copy ofthis record has been provided to the well oivner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tmder#21 remarks section or on the back ofthis 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 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdperent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: 39 (ft,) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Iniection Wells ONLY: In 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:
(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 27699-1636
13a.Yield(gpm) 3 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water lesources Revised August 2013