GW1-2023-02657_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:
Derry L. Hune cuff 14.WATERZONES
') Y FROM TO DESCRIPTION I
Well Contractor Name - - , 265 ft. 280 ft. 2gpm
2663-A APR
p `m' `' ft. ft. I
NC Well Contractor Certification Number H I f� j ���� 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
�• FROM TO DIAMETER THICIQIESS MATERIAL
Derry's Well Drilling, lqq;`.,,;._.;.;,.i 0 ft 145 ft 16 1/8 .'- 1 SDR-21 I PVC
Company Name r,,c ;,,•;;. J 16.INNER CASING ORTUBING(geothermal closed-loop)
22-259 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable well permits(i.e.County,State,Mariance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft ft is
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. & in.
❑lndustriaVCommercial - ❑Residential Water Supply(shared) 18.GROUT
IDRILLING
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 20ft• Bentonite Pumped
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation /GRAVEL PACK ifa licable TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control
ING LOG attach additional sheets if necessa❑Geothermal(Closed Loop) ❑Tracer To DESCRIPTION color,hardness,soil rork a rain size,etc❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 18 f Brown Dirt&Rock
4.Date Well(s)Completed: 2/9/23 Well ID# • 400 ft- Hard Blue Rock
. ft.
5a.Well Location: . ft
Tyler Turner ft ft
Facility/Owner Name Facility ID9(ifapplicable)
Jerusalem Church Rd, Marshville 2$103 a ft Seams:130', 150', 162', 170-175',238',
ft. ft. 265-280'=2gpm
Physical Address,City,and Zip 21.REMARKS
Union 01-036-003C
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N W DA �Z_ � � 3/1/23
Signature of rtified Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that rite 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 ofihis record has been provided to lite well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 reinarks section or on Cite 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 u jection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (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: 38 (ft.) Division of Water Resources,Information Processing Unit,
If mvater 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) 2 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Enduonment and Natural Resources-Division of Water Resources Revised August 2013
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