GW1-2023-01644_Well Construction - GW1_20230213

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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:
John W. Hune cult 14.WATER ZONES l !
Y �i. ;^� l g FROM TO DESCRIPTION I
Well Contractor Name L ".,e �t
`� a c { u�.1.10 r� 73 ft 2 gpm
2465-A FEB 1 ,� ZQ23 165 fL 175 ft f 33 gpm
NC Well Contractor Certification Number `� 15.OUTER CASING for multi cased wells OR LINER if a licahle
FROM TO DIAMETER I TH[CItT1ESS MATERIAL
Derry's Well Drilling, Inc. lnfo;Tm axpn s'mnw�--nij O'd ft• 145 f4 16 1/8 SDR-21 PVC
Company Name v r" ' 16.INNER CASING OR TUBING(geothermal closed-loop)
327230 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. tn.
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in. 1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri ation 0 ft' 3 fL 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)I
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
[]Aquifer Test OStormwater Drainage
R. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiuroch type,puin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 0 fL 7 ft.' Red Dirt
7/27/22 7 rL 32 f4 Brown Dirt&Rock
4.Date Well(s)Completed: Well ID#
32 fL 185 fL I Slate
5a.Well Location: ft. &
James&Sherrill Ann Butler ft. fL
Facility/Owner Name Facility ID#(if applicable) fL' fL , ,— ,
Herrin Grove Rd., Locust 28097 Seams:55,ss',70-2gpm, 140,
rr fL 165'=33gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 139891
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
u�
N w 8/10/22
SignatuffafCcrtified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the•,well(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 ElNo copy ofdris 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 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 wells ONLY with the same construction,you can
submit one forma SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 12 (fL) Division of Water Resources,Information Processing Unit,
Ifwater 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 276994636
13a.Yield(gpm) 35 Method of test- Air 24c.For Water Supply&Injection Wells:;
Also submit one copy of this form within 30 days of completion of art
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health depment of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources, Revised August 2011