GW1-2022-10061_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
John W. Huse cuff 14.WATER ZONES t
Y FROM TO I DESCRIPTION I
Well Contractor Name 308 ft 312 ft I 1 gpm
2465-A
. lo.s @o ft ft
NC Well Contractor Certification Number N O V Z 22 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER i I THICKNESS MATERL►L
Derry's Well Drilling, Inc. , 0 ft 49 ft 61/8 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING fimothermal closed-loon)
21-334 FROM TO DIAMETER!,in.
THICKNESS MATERIAL
2.Well Construction Permit#: fr, ft in.
List all applicable well permits(t.a County,State,Variance,Injection,eta) '
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER •SLOTSIZE TLHCENESS MATERIAL.
❑Agricultural ❑Mutiicipal/Public ft. it in.
❑Geothermal(Heating/Cooling Supply) IIResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 R- Bent.Chips,. Gravity
Non-Water Supply Well: 3 fr. 20 rr. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK'(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To IATERIAL• EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain sire,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under421 Remarks) 0 ft 11 ft Brown Dirt
3/11/22 11 ft 31 & Brown Rock
4.Date Well(s)Completed: Well ID#
31 ft- 485 ft ( Blue Rock
5a.Well Location: % ft
DC Homes ;
ft ft
Facility/Owner Name Facility ID#(if applicable)
6224 Olive Branch Rd., Marshville 28103 ft. ft Seams: 60',80', 130', 177', 199',210',
ft ft 243',308'=1g,336'
Physical Address,City,and Zip 21.REMARKS
Union 02-199-002C j
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Wong is sufficient) a'N W9�� 4/6/22
Sigofiue of Certified Well Contractor Date
6.TS(are)the weil(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 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
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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 485 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In I 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:
(Le.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) 1 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Granular Amount• 1/2 lb. well construction to the county health department of the county where
constructed.
I
Forst GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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