GW1-2023-02673_Well Construction - GW1_20230411

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WELL CONSTRUCTION RECORD For Inlemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwi ht L. Hone cuff 14.WATER ZONES
9 Y FROM TO I DESCRIPTION
Well Contractor Name _ 136 n' 140 it 3 gpm
4070-A _.. ._, ;z �' 379 't 382 fO 1 gpm
t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if ii livable
t A PR 7 '� )023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. Y Llr 0 45 61/8 °n SDR-21 PVC
Company Name ir1;;.; } , ,, , J i_r(l.i 16.INNERCASINGORTUBING eotherm all closed-loo
360648 FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: "' ft. ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
f4 ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNM MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
ROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 IL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 n 20 It- Bentonite Pumped
Injection Well: n• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattach additional sheets it necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,nard,ms,soNruck type,grain s m.etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 5 15L Rocky Brown Dirt
4.Date Well(s)Completed: 2/21/23 Well ID# 5 fw 505 fL Slate
ft. ft.
Sa.Well Location: ft. ft.
Ali Darwich
ft. %
Facility/Owner Name Facility M9(if applicable) ft. IL Seams:57',72',95', 131', 136'=3gpm,
NC Hwy 24/27, Albemarle, 28001 ft. ft. 350',368',374',379'=1gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 25762
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
W 3/1/23
N
�Gtrt. 112Y.`-,� Y,iuZ¢�/�- -
Signature o ertiSed Well Contractor Date
6.Is(are)the well(s): ❑Permanent 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 E}No copy ofthis record has been provided to rite well owner.
If this is a repair,fill out known well consinrction information and explain the nature of the
repair under#21 remarks section or on the back of Arts 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: 505 (IL) 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: 46 (g,) Division of Water Resources,Information Processing Unit,
Ifwater 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 4 Method of test: Air 24c.For Water Supply&IDlection 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.
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Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013