GW1-2023-02692_Well Construction - GW1_20230411

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hune curt 14.WATER ZONES
Y FROM TO DESCRIMON
Well Contractor Name _ 135 ft' 150 ft' 75 gpm
2465-A _ :, .. ` .' 'a:,t'�' ft. ft.
NC Well Contractor Certification Number (� 15.OUTER CASING formulti-cased wells OR LINER if a licable
APR 1 1 �OZ3 FROM TO DIAMETER TmCIINESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 58 ft 16 1/8 in1 SDR-21 I PVC
' °: 16.INNER CASING OR TUBING(eothermal closed-loo
Company Name n;,., l•., :i:.J t,.:
316016 t FROM TO DIAMETER THICKNESS bATERIAL
2.Well Construction Permit#: ft. ft. in.
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 DIMIETER SLOT SIZE THICKNESS MATERUL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geotheal(Heating/Cooling Supply) I3Residential Water Supply(single) ft. ft. in rm
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fa 3 fr- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL PACK if applicable)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT1uETHO11
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Stibsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I To DESCREMON color,hardness soivrock type in sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 5 ft. Red Dirt
4.Date Well(s)Completed: 7/12/22 Well IN 5 ft- 47 ft. Brown Dirt
47 ft 165 ft- Slate
5a.Well Location: ft. ft.
Kolby E. Lamp fL fr.
Facility/Owner Name Facility ID#(if applicable)
NC Hwy 205, Oakboro 28129 (Lot 2) ft. ft- Seams:70',75',90-95', 112', 125',
f, ft. 135'-150'=75gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 10384
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) J �(/
N w � 66• / r 8/11/22
iature of Certified Well ContractV 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 ONo 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 ofthis 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.
t For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 15 (fL) 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: ids 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 Center,I Raleigh,NC 27699-1636
13a.Yield(gpm) 75 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 Revised August 2013