GW1--07565_Well Construction - GW1_20231121

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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:
Dwight L. 'cutt .14.WATER ' I
Hune` -', , -,." ;: .
9 7 FROM TO DESCRIPTION
Well Contractor Name 74 ft' 79 ft I 1 gpm
4070-A ft. , ft . I
NC Well Contractor Certification Nnmler 15.OUTER CASING(for,multi casedvvells)OR LINER(if ap 6cable)-, _ - -.
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 44 ft 6 1/8 :1' 'a SDR-21 PVC .
Company Name -16.INNER CASING'OR TUBING(geothermal closed-loop)' ,.
• 2022-00002349 FROM TO DIAMETER THICKNESS MATERIAL '
2.Well Construction Permit#: 'ft. ft I w-
rist all applicable well permits(i.e.County.State,Variance,Injection,etc.) •
ft. ft,' in. '
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL .
DAgricultural ❑Municipal/Public ft. ft in ';
❑Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft ft. tn.1,
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation , 0 ft 3 In Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft. Bentonite Pumped
-
Injection Well: ' ft. ft.
DAquifer Recharge ❑GroundwaterRemediation :19.SAND/GRAVEL PACK(if applicable) .-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
El Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soi0roch type grain sae.etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 7 ft. - Brown Clay •
5/26/23 7 ft 30 ft Brown Dirt&Boulders
4.Date Well(s)Completed: Well ID# .;'
30 ft, 462 Ttu . .l"il '�-..:plue Granite
5a.Well Location: ft " t.- -- ' I '
James Krysinski ry ft NW/ 6� _ 2023 •
Facility/Owner Name Facility ID#(if applicable)
439 Inwood Rd, Asheboro 27205 ft. tl `''� � I,• :rems:74-79'=1gpm
ft. ,; -:;. :,:.
1,..Y Y J 1.JL,a�
Physical Address City,and Zip ..21.REMARKS -
Randolph % 7760774258
County Parcel Identification No.(PIN)
•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: .
(if well field,one Int/long is sufficient)
N • W Z7G FGt L 7 6/10/23
Signature of C tifiedWellContractor i• 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 ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or EINo copy of this record has'been provided to the well owner.
If this is a repair,fin out known well construction information and explain the nature of the
repair under se21 remarks-section or on the back of this form. 23.Site diagram or additional weltdetails:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ' 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: 275 (ft) 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: 40 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: in 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,mtary,cable,direct push,etc.) 11 .
, Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen ter,Raleigh,NC 27699-1636 '
I Air 24a For Water Supply&Injection Wens: .
13a.Yield(gpm) Method"'of test:
Also submit one copy of this form vyithin 30 days of completion of
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county healthi department of the county where •
constructed. I .
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013