GW1-2023-02643_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hune cuff 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 65 ft. 70 ft 35 gpm
2465-A 145 fL 150 fL 25 gpm
"h 15.OUTER CASING for molts-eased wells OR LINER if a [iwhle
NC Well Contractor Certification Number j 2fj9�
VI CC FROM TO DIAMETER TIIIC[NIF.SS M1fATERIAL
Derry's Well Drilling, Inc. 0 ft 59 ft.
6 1/8 SDR-21 PVC
1°r- 16.INNER CASING OR TUBING Neothermal closed-loop)
Company Name ,`' =) •£ FROM TO DIAMETERTHICIINESS M1LITERIAI
2.Well Construction Permit#: 22-296 ft. ft. in
List all applicable well permits 0.e.County,State,Variance,injection,eta)
ft ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLAMETER SLOT SIZE TRICENFSS MATERIAL
❑Agricultural OMunicipal/Public ft, ft. in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. is
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft- 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 fr. 20 ft Bentonite Pumped
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity,Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft it.
❑Experimental Technology ❑Subsidence Control
20.DRiI,LING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soilfroek a rain s m,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f6 20 It. Brown Dirt
4.Date Well(s)Completed: 3/17/23 Well ID# 20 ft- 50 ft. Junky Blue Rock
50 ft, 205 fl- Blue Rock
$a.Well Location: g• M
Thomas Brady ft. ft ,
Seams:65-35gpm,75,95', 125, 132,
Facility/Owner Name Facility ID#(ifapplicable)
ft ft
2010 New Salem Rd,Monroe 28110(Claudia Beth Mcleod Lt1) 145'-150'=25gpm, 175',190'
Physical Address,City,and Zip 21.RE4fARKS
Union 09-037-001
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwetl field,one ladlong is sufficient) J �(/
N W � "`/, J''�'' 4/3/23
Sig ue of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary 13y signing this form,1 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 EINo copy of this 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
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: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 20 (n-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter- 6 (in.) 24b.For Injection 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 27699-1636
13a.Yield(gpm) 60 Method of test: Air 24c.For Water Supply&In echoes 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013