GW1-2023-02647_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:
Huneycutt 14.WATER ZONES
John W. Hume
Y FROM TO DESCRIPTION
Well Contractor Name 310 ft 347 ft. 3 gpm
2465 A ft. f,
NC Well Contractor Certification Number 15.OUTER CASING far multi cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR 1 1 2023 0 ft- 60 ft- 61/8 SDR-21 I PVC
Company Name ^y^- 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 22; 77^ ._ ' ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f6 ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Z1Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 H' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 f` Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness soiUmck type,gFuln sim,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 25 ft. Brown Dirt
4.Date Well(s)Completed: 3/2/23 Well ID# 25 ft- 380 ft. Blue Rock
ft. ft.
5a.Well Location: ft. ft.
Clint Burch
fr. fr. Seams: 105', 108', 118', 135', 155',
Facility/Owner Name Facility ID#(ifapplicable)
6319 Ri ins Rd, Marshville 28103 f6 IL 185'=2gpm,215',235',270',310-347'=1gpm
99 ft. ft.
Physical Address,City,and Zip
21.REMARKS ,
Union 03-114-009C
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) // 1
N W rG� Lt/. 3/14/23
Sign. of Certified Well Contractor 61 Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 ofthis 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 ofthisform. 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: 380 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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
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
(Le,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) 3 Method oftest• Air 24c.For Water Su(rply&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 of Environment and Natural Resources-Division of Water Resources Revised August 2013