GW1-2022-10080_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single at multiple wells
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1.Well Contractor Information.
Dwight L. Hune cuff %� a. - 14.WATER ZONES
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- Yj jam„ HI FROM TO I DESCRIPTION
Well Contractor Name 209 n' 218 n' I I 4 gpm
4070-A NOV 0 7 2022 n. n.
NC Well Contractor Certification Number 15.OUTER CASING far mulfi-caved wells OR LINER if u licable
IrkGi11@:U,D'1 i�PiC.x "` Un FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. rto.0 MOG 0 fL 145 fL 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING( eotbe at dosed-loop)
21-319 FROM TO DIAMETER TIRCRNESS I MATERIAL
2.Well Construction Permit#: n. n. �•hL
List all applicable well permits(z.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. % in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Dirrigation
Non-Water Supply well 0 ft' 3 n Bent.Chips Gravity
❑Monitoring ❑Recovery 3 R' 20 ft: Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier Fitollt TO nIATEIu u. EMPLACF11fENT METHOD
ft. ft.
❑Aquifer Test ❑StortrvaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'LOG(attach additional sheets if necessary!
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hatdness.soil/roekri rain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 13 ft Brown Dirt
8/22/22 13 fL 300 fL Slate
4.Date Well(s)Completed: Well 1D#
ft fa
5a.Well location: ft. ft.
Darren Jenkins
ft. n.
Facility/Owner Name Facility ID#(ifapplicable) ft. fL Seams:57',75', 138', 190', 193',209'=4gpm
5114 Landsford Rd., Marshville 28103
Physical Address,City,and Zip 21.RF.NIARKS
Union 03-063-001A
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County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification'
(if well field,one latlhong is sufficient)
N w I, 9/15/22
Signature o Cettified Well Contractor Date
6.IS(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that:the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACi02C.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 otmer.
/fthis is a repair,fill out known well construction Information and explain lire nature of the
repair tinder all 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
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-watensupply wells UM.Ywith the same construction,you can
subnil one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100') construction to the following:
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10.Static water level below top of casing: 28 (g) Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use ' 1617 Rfail Service Center,Raleigh,NC 27699-1617
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I I.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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.) t
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Afail Service Cei ter,Raleigh,NC 27699-1636
24a For Water Supply&Injection Wells:
13a.Yield(gpm) 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 Res otirces Revised August 2013
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