GW1-2023-01734_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 11
1.Well Contractor Information:
Derry L. HuneY curt 14.WATER ZONES
FROM TO DESCRIPTION i
Well Contractor Name ^' �h r ' 125 fk 135 ff• I 5 gpm
2663-A `'`_ ft. ft. i I
NC Well Contractor Certification Number FEB L 2�23 15.OUTER CASING for multi-cased we11s OR LINER if a licable
FROM I TO DIAMETER f T MATERIAL
Derry's Well Drilling, Inc. ; L o fL 107 fL 61/8 i" I SDR-21 I PVC
16.INNER CASING OR TUBING eothcrmal closed-loop)
Company.Name '°a tIu 0G
338014-2 FROM TO DIAMETER ' THICKNESS MATERIAL
2,Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.a County,State,Variance,Injection,etc.) '
ft. ft m.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural 17MunicipaUPublic fL ft
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL fL in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oftrigation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery. 3 ft- 20' fL Bentonite: Pumped
Injection Well: ft. ft.
ClAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
`
❑ FROM TO ➢IATERIAL i EMPLACEMENT METHOD
Aquifer Storage and Recovery ❑Salinity Barrier fr. ft. '
❑Aquifer Test gStormwater DrainagefL fL 1,
❑Experimental Technology ❑Subsidence Control
20.DRILLING:LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMOx color hardness sail/rack type in size,ere
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 10 ft Red Dirt
4.Date Well(s)Completed: 7/2/22 Well ID# 10 go ft Brown Sandy Dirt
90 ft 265 ft- Brown Rock
5a.Well Location: R ft.
Chase&Morgan Idol ft f4
Seams: 115,125'=5gpm,145, 157',
Facility/Owner Name Facility ID#(if applicable)
107 Riverhills Trl, Rockingham 28379 f`f6 f` 1s5',230'
ft.
Physical Address,City,and Zip 21 REMARKS
Richmond 743502666654
,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) I
N w
D ,,�, � I 7/29/22
Signature of ' ed Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that Ithe wells)ivas(were)constructed in accordance
ivith 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 BNo copy of this record has been provided to the well owner.
If this is a repair,fill out knmvn well construction information and explain the nature of die
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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-watersupply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCI•IONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferent(example-3@200 and 2 a@100) construction to the following:
,
10.Static water level below top of casing: 36 (fG) 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 0-) 24b.For iniection 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: {
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,'Jnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 5 Method of test: Air
24c.For Water Supply&Injectioniwclls:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
Granular Amonnt: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW4 North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013