GW1-2023-02695_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hume cuff 14.WATER ZONES t
Y FROM TO I DESCRIPTION 1
Well Contractor Name 77 rL 81 fit II 1 6 gpm
2465-A �. ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR l 1 2073 0 ft 51 ft. 6 1/8 is SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER' TnICKNESS MATERIAL.
2.Well Construction Permit# 384736 J `;t;%t ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Inrectiod;z;
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNESS 11LATERIAL
fL ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. fL in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 1 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fr. TO ft. MATERIAL EMPLACEMENT METHOD
❑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,soitlrock type rain she eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft. Brown Dirt
1/2/23 25 ft- 245 f` Granite
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. f4
Ed Ashmore
rL fL Seams:77-81'=6gprn,93',215'
Facility/Owner Name Facility ID#(if applicable)
fL ft.
33049 Old Salisbury Rd.,Albemarle 28001 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 18942
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) gort, a /
N W jam'(// 2/1/23
Si tune of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the stone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3@200'and 2@i00) construction to the following:
10.Static water level below top of casing: 36 (ft,) Division of Water Resources,Information Processing Unit,
lfivater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6 24b.For Injection Wells ONLY: hi 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 Injectiou Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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.
i
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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