GW1-2023-02675_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:
cuff 14.WATERZONES
John W. Hume • i
Y FROM TO DESCRIPTION I
Well Contractor Name 317 ft 320 ft 89pm
2465-A _ ft. ft.
NC Well Contractor Certification Number r'^G { a" 1 " 15.OUTER CASING for multi cased wells OR LINER d a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. p 0 ft' 107 ft 61/8 is SDR-21 PVC
Company Name APR.R 1 s J 16.1NNER CASING OR TUBING(geothermal closed-loop)
115870 FROM TO DIAMETER THICKNESS MATERL�I
2.We1lConstructionPelwit#: �n Ut+:i ft. ft. in.
List all applicable well permits(i.e.County,State,Ygri c(;•lnjectitin ere) �,•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERLII,
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft' ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM J TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
3 rc. 20 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. f4
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets itnecess
❑Geothertmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrocittype,grAu size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R- 20 ft Red Dirt
4.Date Well(s)Completed: Well 1D#
7/23/22 20 ft 100 ft Brown Dirt&Rock
100 fL 345 it Blue Rock
5a.Well Location: ft. ft.
Jeffery Ridenhour ft. ft.
Seams:115', 130', 135', 155', 169', 192',
Facility/Owner Name Facility 00(if applicabl)
46407 WhitneyI, New London 28127 ft. ft 210',215',230',277',317'=8gpm
Y ft. ft.
Physical Address.City,and Zip
21.REMARKS
Stanly 21428
County Parcel identification No.(PIIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Geld;one Wong is sufficient)
N Wgt-`LyG 8/15/22
Sio6ture of Certified Well CoutractoV Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify char the well(s)was(were)constructed in accordance
with I5A 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 END copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction liformalion and explain lite nature ofthe
repair under r21 remarks.section or on the back of this•farm. 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 injection or nan-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Totalwell 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 ifdifferem(example-3@200'mull@I00') construction to the following:
10.Static water level below top of casing: 33 Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 I.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 27699-1636
13a.Yield m 8 Method of test: Air 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disillfectiontype: Granular Amount: 1/2 Ib. well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Reso es Revised August 2013