GW1--01999_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
John W. Hune cuff 14.WATER ZONES i
y FROM TO DESCRIPTION
Well Contractor Name 78 ft. 92 It I 3 gpm . .
2465-A 145 ft 150 ft I , 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER i THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 52 ft 6 1/8 I in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING.(geothermal closed-loop)
373536 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. I in.
List all applicable well permits(I.e.County,State,Variance,Injection,etc.) ft. ft. I in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public H. ft. in.
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation . 0 ft 3 it Bent.Chips Gravity
Non-Water Supply Well;
❑Monitoring ❑Recovery 3 * 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑$allnity Barrier FROM TO MATERIAL' - EMPLACEMENT METHOD
ft. ft. i; .
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary) .
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type;grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 it Brown Dirt
8/4/23 25 ft 45 ft 1 Shale
4.Date Well(s)Completed: Well ID#
45 it 245 re. Slate
5a.Well Location: ft. ft.
Jamie Poplin ft. ft
Facility/Owner Name Facility ID#(if applicable) Seams:70,7&92—3g,107, 115', 125,,
ft.
40053 Mountain Creek Rd., New London 28127 ft.
.. 145'=4g, 170', 195',215'
ft ft.
Physical Address,City,and Zip 'TM'
21.REMARKS• ;
r•.'6 . l .;' i as' o i .1
Stanly 19849 a
County Parcel Identification No.(PIN) i' A rr R V, S 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ? t
(if well field,one lat/long is sufficient) // � �� // Inv'�i'''rv:`n » r'"'✓^'iv.g VTF
N W
�GJTi (if/. I. • 4 ' 8/30/23
Si a of Certified Well Contractor i Date
6.Is(are)the well(s): ®Permanent or OTemporary By signing this form,I hereby cergi that the we/I(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this 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 t
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3(a3200'and 2@100) construction to the following:
10:Static water level below top of casing: 30 ({t) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i.
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(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) 7 . Method of test: Air 24c.For Water Supply&In(ectlon 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
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