GW1--01991_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Hume ff 14.WATER ZONES 4
cu
Y FROM TO DESCRIPTION
Well Contractor Name 135 ft- 137 ft. I 3 gpm
2465-A 142 ft- 146 ft 1 ; 17 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
FROM TO DIAMETER i ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 45 ft- 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
403960 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. hi.
List all applicable well permits(Le.County.State,Variance,Injection,eta)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft II in.
OGeothermal(Heating/Cooling Supply) I lResidential Water Supply(single) it ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrigation • 0 ft. 3 f° Bent Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 ftBentonite' Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. ,
❑Aquifer Test ❑Stormwater Drainage
ft. ft. .
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soWraek type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 11 20 ft. Brown Dirt
12/21/23 20 it. 165 14 Blue Rock
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Roy Furr
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:50',75',81', 110', 135'=3g,
20257B Claude Dr., Albemarle 28001 ft. ft. 142'=17g
.
Physical Address,City,and Zip 21.REMARKS I 't 1,,_o ff.:i r °.-.>i
Y
Stanly 8515 •
County Parcel Identification No.(PIN) i APR
d 1 (0I4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1nf.a r�r:i,c^^;t Pr.-' -g.
(if well field,one latilong is sufficient) �~� :':,;f(.lA
L�""-';115713
N W
Si of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby cert?ty that the well(.)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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 of this 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: 165 (ft.) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ljdifferent(example-3@200'and 2@100) construction to the following: 1
10.Static water level below top of casing: 30 (ft.) Division of Water Resourc •
es;Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
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)20 - - , - 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 OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013