GW1-2023-01645_Well Construction - GW1_20230213

I'
WELL CONSTRUCTION RECORD For Internal Use ONLY: !
This form can be used for single or multiple wells i
1.Well Contractor Information: I4
Dwi ht L. HUne cuff `14.WATER ZONES'- i
g y FROM I TO DESCRH'TIONI I
Well Contractor Name 188 ft 192 ft I I 8gpm
4070-A _ tt• I ft f
NC Well Contractor Certification Number pr^� t 15.OUTER CASING'for multi cased wells OR LINER if a licable -
s '+�'„„„ ,pq a �� =s''� FROM TO DIAMETER i THICKNESs MATERIAL
Derry's Well Drilling, Inc. 0 161 ft 16 1/8 SDR-21 I PVC
_
Company Name ✓ 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO I DIAMETER " THICKNESS MATERIAL
366293
2.Well Construction Permit#. ft. ft. is
List all applicable well permits(t.e.County,S1a(, ttiance,Iq�r�eh�,OGy y ft ft
3.Well Use check well use):(- ) 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft &
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 u 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK if applicable)
'.
FROM I TO MATE UL EMPLACEMENTAIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. j
❑Aquifer Test ❑Stormwater Drainage
ft. ft. �
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESt RUMON color,hardness,somrock type,gr_afti size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. g ft. I' Red Dlrt
4.Date Well(s)Completed: 7/2/22 Well ID# 9 ft 28 e. i1 Brown Dirt
28 ft 35 ft Brown Rock
Sa.Well Location: 35 ft 265 ft Slate
Stanly Construction ft ft
Facility/Owner Name Facility ID#(if applicable)
Austin Rd., Albemarle 28001 & Seams:,72,77',90', 113', 117', 132',
ft ft. 188'=8gpm, 195'
Physical Address,City,and Zip 21,REMARKS `
Stanly 19638
County Parcel Identification No.(PIN) 4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) /
N W .[. . GCuLC 8/1/22
Signature o Certified Well Contractor Date
6.I5(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the[well(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 0No copy of this record has been provided to the we11 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 piovide 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: 265 (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: I'
10.Static water level below top of casing: 32 ({t) Division of Water Resources,Information Processing Unit,
Ifrvater 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
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
(ie.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
24c.For Water Supply&Injection Wells-
Also Yield(gpm) $ Method of test: Air !
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources) Revised August 2013