GW1-2023-01608_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD For hitcmal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. HUne "CUtt 14.WATERZONES, A
g Y FROM TO I DESCRH'TIONI I
Well Contractor Name 172 ft 180 ft Il I 5 gpm
4070-A 7` — ft. ft. I
NC Well Contractor Certification Number
w E--- �-®,e �i� E�,. 15.OUTER CASING for multi-cased wells-OR LINER"if a licahle
FROM TO DIAbETER I I TIIICIflVESS MATERIAL
Derry's Well Drilling, Inc. FEB 1 c 2023 0 ft- 45 ft 61/8 hiI"i ; SDR-21 PVC
Company Name 16.INNER'CASING OR TUBING eothermal closed-loo
22-231 TO DIAMETER 11. 'TffiICVFSS MATERIAL
2.Well Construction Permit ft ft. in
List all applicable well permits(i.e.County,State,Variance,Injection e18.
ft. ft in:
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICENESS MATERIAL
❑Agricultural ❑Municipal/Public ft in
❑Geothermal(Heating/Cooling Supply) I231tesidential Water Supply(single) fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable),
FROM TO MATERIAL i; � EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft •
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft fr.
20.`DRUAJNG LOG attach additional`shiiets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON color hardness,soillrock type,gron size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 6 ft Brown Dirt
a.Date Well(s)Completed: 9/29/22 Well ID# 6 a 14 ft Brown Rock
14 ft 300 ft. Slate
5a.Well Location: & ft
Kailey Simpson Herr ft. ft.
Facility/Owner Name Facility ID#(if applicable) r
ft ft. Seams:52',597,75',113',134',
6307 New Hope Church Rd., Marshville 28103 ft. ft. JI; 172'=5gpm
Physical Address,City,and Zip. 21.REMARKS
Union 01-17MOW
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: !
22.Certification:
(ifwell field,one lat/long is sufficient)
x w
10/16/22
Sigaature of Certified Well Contractor Date
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this form,I hereby certify that the I4vell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided io the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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
S.Number of wells constructed: 1 construction details. You may also ittacd additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the sane construction,you can SUBMITTAL INSTUCTIONS i
submit one form
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 tfdierent(example-3@200'and 2@I00) construction to the following:
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10.Static water level below top of easing:
40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center Raleigh,NC 27699-1617
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11.Borehole diameter` 6 (in.) 24b.For Iniection Wells ONLY: in addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following- r
(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) 5Method of test: Air 24a 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 ofEnvironment and Natural Resources—Division of Water Resourcesi Revised August 2013
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