GW1-2023-02653_Well Construction - GW1_20230411

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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 14.WATER ZONES
ycutt FROM TO DESCRIPTION
Well Contractor Name 216 "' 220 ff 2 gpm
2465-A 330 ft- 336 ft- 2 9PM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased W lls)O (ifaupticable)
APR 2023 FROM I TO I DIAMETER OR
MATERIAL
Derry's Well Drilling, Inc. 0 ft- 60 ft 6 118 . in- I SDR-21 PVC
Company Name 16.INNERCASINGORT
UBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit N: 22-242 ft. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER, SLOT SIZE I THICKNESS MATERIAL__
DAgricultural CMunicipal/Public ft. ft.
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft
in
ElIndustrial/Cominercial OResidential Water Supply(shared) 13.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation 0 ft 3 ft- Bent.Chips Gravity
Non-WaWr Supply Well: EIRecovery 1:1 onitoring 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. ft.
0Aquifer Recharge []Groundwater Rentediation 19.SAND/GRAVEL PACK(ifapplicable)
DAquifer Storage and Recovery CiSalinity Barrier FROM-_ft. TO ft. MATERIALI EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft. T
DExperimental Technology DSubsidence Control 20.DRILLING LOG(attach additional sheets if nece I ssary)
DGeothermal(Closed Loop) OTracer FROM TO DFSCRIEPTION(color,hardness,soil rock type,grain size,etc.)
ElGeothermal(Heatinw—cooling Return) DOther(explain under#21 Remarks) 0 ft 25 ft Brown Dirt
4.Date Well(s)Completed: 9/12/22 25 ft 50 ft Shale Rock
Well IDN
50 ft- 345 ft- Blue Rock
5a.Well Location: ft. ft.
Pat Sherwood ft. ft- Seams: 7',90',95', 105', 115', 130', 137',
Facility/Owner Name Facility M#(if applicable)
ft "t 145', 155', 175', 188',205',216'=2gpm,230',
9006 E. Hwy 218, Marshville 28103 ft. ft. 250',272',291',325',330'=2gpm
Physical Address,City,and Zip 21.REMARKS
Union 01-066-022D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifw ell field,one lat/long is sufficient)
N —W w r 10/1/22
Sign of Certified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify 1ha;1 the 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: OYes or KINo 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 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 attach additional pages if necessary.
For multiple ayecuon or non-water supply ivells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifilifferent(example-3@200'and 2@ 1001 construction to the following:
10.Static water level below top of casing., 35 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter. 6 (in.) 24b.For Iniection Wells ONLY: Inladdition 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
(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) 4 Method of test- Air 24c.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.
FormGW-1 North Carolina Department of Environment and Natural Resources—Division ofWatet R6o.urces Revised August 2013