GW1-2022-10024_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD !
For Internal Use ONLY: ` I
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwi ht L. Hune cuff 14.WATER,ZONES
9 y FROM TO I DESCRIPTION
Well Contractor Name R F'"G 5' ice. , 115 " 120 R' I I 75 gpm
4070-A q qq a. ft I I
NC Well Contractor Certification Number N O V O f ry LOLL IS.OUTER CASING for multi cased wells 0R'LINER if licable
FROM TO- DIAMETER !. TffiCKNESS MATERIAL _
Derry's Well Drilling, Inc. ln�Q-�„�;• n Pr ,xw�kntl UnR 0 ft 46 ft 61/8 �; SDR-21 PVC
.w •� rt-r
Company Name DVIQIBOG 16.INNER CASING OR TUBING(eotherroal closed-loop)
376363 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft.. fG RL
List all applicable well permits(i.e.County,State,Variance,Infection,eta)
ft fL i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. hr
❑Industnal/Commercial ❑Residential Water Supply(shared) IS:GROUT
FROM TO MATERL&L EMPLACEMENT METHOD&AMOUNT
mIrri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft. bentonite Pumped
Injection Well: R ft
[]Aquifer Recharge ❑Groundwater Remediation M SAND/GRAVEL PACK if a licable
FROM TO 5ATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attic'additional sheets if neces
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON color,hardness softock type,grain site,etc
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 ft. I: Brown Dirt/Rock
4.Date Well(s)Completed: 6127/22 Well ID# 16 n 125 ft- i, Slate
& ft. I;
Sa.Well Location: ix ft
Richard Almond ft. n ;
Facility/Owner Name Facility ID#(if applicable)
1010 Lafayette Dr., Albemarle 28001 ft. & Seams:52',57',75-79', 115'=75gpm
i.
Physical Address,City,and Zip,
Zl.REMARKS.
Stanly 27226
County Parcel Identification No.(PIN)
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5b.Latitude anti Longitude in degrees/miuutes/seconds or decimal degrees: j
22.Certification:
(ifwell field,one fattlong is sufficient)
N R, 7/18/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thatl 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 91No copy of this record has beeri 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 thisform. 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 h jection or non-water supply wells ONLY with the same construction,you can �•
submit one form. SUBMITTAL INSTUCTIONS ;
9.Total well depth below land surface: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#d fferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 16 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Ceutee,Raleigh,NC 27699-1617
11.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,fort within 30 days of completion of well
12.Well construction method: Rotary construction to the following: I`
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cete,Raleigh,NC 27699-1636
75 Air 24a For Water Sup
ply&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: 112 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 2613
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