GW1--02000_Well Construction - GW1_20240401

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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 cutt 14.WATER ZONES-_ i
Y FROM TO DESCRIPTION
Well Contractor Name 110 It 115 ft I ' 6 gpm
2465-A 135 ft 137 ft- I i 1 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER ,' THICKNESS MATERIAL Derry's Well Drilling, Inc. o ft. 49 ft 6 1/8 !I"- SDR-21 PVC _
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
384206 FROM TO DIAMETER : THICKNESS MATERIAL
2.Well Construction Permit#: ft ft i,*-
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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft Brown Dirt&Rock
8/5/23 25 ft 225 ft • Slate
4,Date Well(s)Completed: Well DM
ft ft. j•
5a.Well Location: ft ft.
Jason Roberts
It it Seams-257',62',75',80',95', 110-115'=6g
Facility/Owner Name Facility IV/(if applicable) -
42857 Blalock Rd., New London 28127 ft ft 120',135'=1g, 190',210'
ft ft . "..-,, z j,r y,
Physical Address,City,and Zip 21.REMARKS ; F w�4--e;6,,,4 ,e 4,
Stanly 11514 �q
County Parcel Identification No.(PIN) H;I R 4, 1 2 G 2h
,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: tn�:Ii ~y:!�+I?` "'� 'v R
9
(ifwell field,one lat/long is sufficient) �� 1 L j4r O,l:30 y
N W . J , 8/30/23
Si page of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to the iseli 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 I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (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: 30 (ft,) Division of Water Resources;Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1.
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: .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent j r,;Raleigh,NC 27699-1636
7 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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