GW1-2023-01640_Well Construction - GW1_20230213

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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.
DerryDer L. HUne CUtt `14.WATERZONES P }"
y FROM TO DESCRIPTION I
Well Contractor Name 148 ft 150 ft 2 gpm
2663-A '- °' �x V-'x�yy 270 ft 280 ft I .8 9Pm.
/ p 5 15.OUTER CASING for multi-cased wells OR LINER if a licable
NC Well Contractor Certification Number F `7
Y FROM TO DIAMETER ( THICKNESS MATERIAL
Derry's Well Drilling, Inc. 1rr;�i'R7;<,;,' v n?� 0 ft 45 ft- 6118 SDR-21 PVC
H.ar,
Company Name (j(;p�y-� -��n 16:INNER CASING OR TUBWG Ncotheirmal closed-too '
315345 W �tr,:t FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft
List all applicable well permits(L e.County,State,Variance,Injection,etc.)
ft. I ft.
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: FROM :' TO DIAMETER SLOT SIZE ITUCENESS MATERIAL
ft ft. in•
[]Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) it tt is
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft 3 ft 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 a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft ft. {
❑Aquifer Test ❑Stormwater Drainage
ft. ft j
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardneu soil/rack type,grainsae eta
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 ft. it Brown Dirt
4.Date Well(s)Completed: 4/8/22 Well ID# 10 ft 305 ft- ;, Blue Hard Rock
ft ft
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5a.Well Location: ft. ft. I
Neil Burleson
it I•(if app Facility/Owner Name Facility I Seams:;67',88',94',100', 148'=2gpm,
lkl licable)
25071 Odell Dr., Albemarle 28001 ft f` 165',�175',215',245',270'=sgpm
ft ft I
Physical Address,City,and Zip 21.REMARKS
Stanly 5038
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
N W 5/1/22
Signature ofd6rtified Well Contractor ii Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this for#;I hereby certify that Ihe!`wcu(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A 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 we'll 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 farm. 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: 305 (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@I00) construction to the following:
10.Static water level below top of casing: 30 (fG) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
II.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) 10 Method of test: Air Me.For Water Supply-&Injection Welisi
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.
Farm GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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