GW1-2023-02688_Well Construction - GW1_20230411

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hume cuff 14.WATERZONES
'
Y FROM TO I DESCRIPTION
Well Contractor Name 215 ft. 220 ft 2gpm
2465-A 417 ft 445 ft 3 gpm
NC Well Contractor Certification Number '"' 4r ?-', 15.OUTER CASING for multi-cased wells OR LINER if a Bcable
FROM TO DIAMETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. APR 1 1 2023 0 ft. 48 ft 61/8 . is I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING Neothermal closed-l000l
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3658�'6''!'11 5, ft ft in.
List all applicable well permits(i.e.County,State,Variance,Injection etc.) u ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipa/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft in
❑hidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft Bent,Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft Red Dirt
1/31/23 5 ft. 25 ft. Brown Dirt
4,Date Well(s)Completed: Well ID#
25 ft 465 fk Blue Rock
5a.Well Location: fc ft
Pinnacle Homes USA LLC
ft ft Seams:53',57',63',80',85',90', 113',
Facility/Owner Name Facility ID#(if applicable)
ft fL 135', 151',215'=29pm,233',317',337',
Ridgecrest Rd, Locust 28097 (Lot 3)
Physical Address,City,and zip ft' ft. 355'=1gpm,397',417-445'=3gpm
21.REMARKS
Stanly 447
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)
N W C�dl� w• GUZ¢c/lt 2/14/23
Sigma of Certified Well Contractor Date
6.Is(are)the well(s): 101'ermanent or ❑Temporary By signing this form,I 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 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 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: 465 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) 6 Method of test: Air 24c.For Water Supply&Infection 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 Fnvirontnent and Natural Resources—Division of Water Resources Revised August 2013
I