GW1-2021-00843_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwi ht L. Hune�/cuff 14.WATER ZONES
g 7 FROM To DESCRIPTION
Well Contractor Name 270 R. 280 ft• 150 gpm
4070-A IL rL
NC Well Contractor Certification Number 15.OUTER CASING for multi<esed wells OR LINER d a lieable
FROM TO DIAMETER THICKNESS DtA'CERIA[.
Derry's Well Drilling, Inc. 0 145 m 6 1/8 ' in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(peother at closed-loop)
353807 FROM To DIAMEIIR TMCKNNTSS MATERIAL.
2.Well Construction Permit#: 0 tt. 100 ft. 4 in SCH 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
It. R. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAWTER SLOT SITE THICKNESS MATERUL
❑Agricultural ❑Municipal/Public R. in
❑Geothermal(Heating/Cooting Supply) ®Residential Water Supply(single) M ft. in.
❑lndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPI.ACEDIEAT METHOD&AM511N-
❑hri ation 0 It. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
[]Monitoring ❑Recovery 3 h 35 R Bentonite Pumped
Injection Well: 0 ft. 100 It- Cement Gravity
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery []Salinityft. ft.FROM
Barrier FROM To DIATERLAL IIitPLACEAiII�I METHOD
❑Aquifer Test ❑Stormwater Drainage
D. ft.
❑Experimcmal Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Gcothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrack eype,grain size,etc.
El Geothermal (Heating/Cooling Return ❑Other lain under#21 Remarks 0 f 12 ft Brown Dirt
4.Date Well(s)Completed: 4/5/21 Well ID# 12 ft 17 ft Brown Rock
17 285 f< Slate
5a.Well Location:
Wayne Eudy
Facility/Owner Name Facility IDk(ifapplicable) ft e. Seams: 133',270'=1509
30681 Kidd Rd., Albemarle 28001
ft. 11.
Physical Address,City,and Zip j
21.REMARKS
Stanly 33135
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) I;
N W �Gtir� � 6/31/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I herebv certify that the well(s) constructed(were)consrcted in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an ezisdng well: ❑Yes or EINo copy of this record has been provided to the,vell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 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: 285 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,(jerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 12 (g,) Division of Water Resources,Information Processing Unit,
If,vater 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
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:
(Le.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) 150 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