GW1-2022-10031_Well Construction - GW1_20221107

i
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
i (1
g Y FROM TO DESCRH710N
Well Contractor Name + y� A 6 �I r 155 R' 162 ft' I 2 9Pm
4070-A NOV
ft 360 ft I 5 gpm
NC Well Contractor Certification Number N O V 0 7 2022 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO- DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. Unit o t. 97 ft 61/8 !; SDR-21 PVC
nods
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
371346 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well permits(i e.County,State,Variance,Injection,etc.)
ft. ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. It.
in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 IL 3 rt Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery _ 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft. i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑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,soillroek tyiie sim etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fL 9 ft Red Dirt
5/21/22 9 ft 43 ft Brown Dirt.
4.Date Well(s)Completed: Well ID# 43 ft S5 ft. Brown Rock
5a.Well Location: 85 ft 400 ft Slate
Blake Underwood ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft Seams: 101', 115', 155'=2g,313',
Kendall's Church Rd., Albemarle, 28001
ftft 352'=5g
Physical Address,City,and Zip 21.REMARKS,
Stanly 140856
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: j
22.Certification:
(ifwell field,one lattlong is sufficient)
N W ewe ,L, I 6/15/22
Signature dfCcrtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that Ilhe well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well oivner.
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
S.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 INSTUCITONS
9.Total well depth below land surface: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mu/ttpie wens list au depths ifdii ferent(example-3@200 and 2@100) construction to the following: �
10.Static water level below top of casing:,
32 (ft.) 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 Iniection Wells ONLY: Ift 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 276994636
13a.Yield(gpm) 7 Method of test: Air , 24c.For Water Supply&Injection Wells:
Also submit one copy of this form iwithin 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