GW1-2021-05809_Well Construction - GW1_20210709

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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 curt � ��� 14.FROM ER ZONES
'7 Y ►,� � FROM TO DESCRIPTION
Well Contractor Name ® 215 fL 220 ft. !' 5 gpm
2663-A �`�� a 2021 272 fL 280 ft' 13 gpm
NC Well Contractor Cert fication Number p`ocess;(Jg OFROtUTER CToSiNG for moult MEs d ells ORAL R i s ►i MATERIAL
Derry's Well Drilling, Inc. In1ormaWN SeoYlon 0 ft' 52 ft. 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
118664 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. in.
List all applicable well permits(i.e.County,State,parlance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑O Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. la
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 fL 35 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 To MnreRIAL eMPLAcent>Nr r>ETaou
[t. 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,soiltrock tyM gnin sin,etc.
❑Geothernnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 ft. Red Dirt
4/19/21 11 ft- 25 ft. Brown Dirt
4.Date Well(s)Completed: Well TD# 25 ft 300 ft• Slate
5a.Well Location: ft. ft.
Philip& Shelby Smith ft. rt.
Facility)0wnerName Facility iD#(if applicable) ft fL
Seams:89', 116', 154',215'=5g,
5431 Linmac Farm Rd., Oakboro 28129 ft. rt.
272'=13g
Physical Address,City,and Zip 21.REMARKS
Stanly 37899
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 � 5/1/21
Signature of rtitied Well Contractor Date
6.Is(are)the well(s): OPermanent or 07femporary Ry signing this form,I hereby certify that the well(v)was 6vere)constructed in accordance
with I5ANCAC 02C.0100 or ISA N(.AC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the well owner.
Ifthis is a repair,fill our known well consiruetion information and explain the nature ofthe
repair under r21 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: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifd�erem(example-3@200'and 2 a t 00') construction to the following:
10.Static water level below top of casing: 31 (ft.) Division of Water Resources,information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Canter,Raleigh,NC 27699-1617
II.Borehole diameter: 6 24b.For injection]Yells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form Athin 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR]]LATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.]'field(gpm) 18 Method of test: Air
24c.For Water Supply&Injection,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 I Revised August 2013
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