GW1-2022-10016_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hune cuff Ia.wATERzoNEs !i t
Y FROM TO I DESCRIPTION i
Well Contractor Name � 175 ft 180 It, 1 gpm
2465-A '�„e E I N"ED 285 ft 290 ft 1 gpm
NC Well Contractor Certification Number (� 15.OUTER CASING for multi-cased we Is OR LINER iCu licable
N O V 0 ' Z022 FROM TO DIAMETER* T THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 145 , ft 6 1/8 SDR-21 I PVC.
Company Name f r uf:it 2n tproC:=-.92g UnA 16.INNER CASING OR TUBING eothermal closed-loop)
OG FROM I TO I DIAMETER THICKNESS aATERIAL
2.Well Constriction Permit#: ft fr. HL
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft It. in '
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) CL fr• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ,ft- Bent.Chips Gravity
Non-Water Supply Well:
3 rr. 20 fr. gentonite 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 TO 1•rATERCAI EMPLACEMENT AIETBOD
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,soill nrk fype size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft• 12 ft Red Dirt
7/30/22 12 rt 23 ft- i Brown Dirt/Rock
4.Date Well(s)Completed: Well ID#
23 ft 405 ft Blue Rock
5a.Well Location: ft ft i
Timothy B. Davis ft ft
Facility/Owner Name Facility ID#(if applicable)
4222 Plank Rd., Wadesbor0 28170 ft ft Seams:88% 117% 175'=1gpm,285'=1gpm
ft. ft
Physical Address,City,and Lip 21.REMARKS
Anson
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees; 22•Certification:
(ifwell field,one lattlong is sufficient) ', l
L[d/ZNi N W W. 8/21/22
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S'ltY ature of Certified Well Contract Date
6.Is(are)the well(s); GUPermanent or ❑Temporary By signing this form,I hereby certo that the well(s)was(were)constructed in accordance
with 15A NC-AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONd copy ofthis record has been provided 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 of this form. 23.Site diagram or additional Nell 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 wells ONLY with the same conwitcdon,you can
submit one form. SUBMITTAL INSTUCTIONS ;
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 wells list all depths ifdijferent(example-3(200'and 2Qa 100) construction to the following:
10.Static water level below top of casing:
38 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rose"+" 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection 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 construction to the following: l',
(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 2769971636
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13a.Yield(gpm) 2 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form jwhhin 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