GW1-2023-01650_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
Der L. Hune cuff 14.WATER ZONES
t r
Derry Y FROM TO I DESCRIPTION)
Well Contractor Name '" "or ', '' ' -•— 112 ft 115 ft I 15 gpm
2663-A �. .rya �" '' 168 ft 175 ft- 5 gpm
NC Well Contractor Certification Number ��B 1 Z�23 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. In ;,-,_„ ,, �� 0 ft 53 ft 61/8in. IsbR.21 PVC
Company Name t rd e`(� Z ''t 16.INNER CASING OR TUBING(geothermal closed-loo
375994 ' 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. is
3.Well Use(check well use): '17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 1t ft 1n
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 H` 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 1t Bentonite Pumped
Injection ell: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM I TO MATERIAL EMPLACEMENT I%WTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRII,LING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,saillrack typc in size.etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 1t Red Dirt
4.Date Well(s)Completed: 12/1/22 Well IDf/ 10 ft 25 ft Brown Dirt
25 ft 200 ft• j; Slate
So.Well Location: ft &
Kendal Harless ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft fL Seams:69',74%98', 112'--15gpm, 121',
Ridgecrest Rd., Locust 28097 ft. ft
150, 168-5gpm, 195,
Physical Address,City,and Zip
21.REMARKS
Stanly 32019 i
County Parcel Identification No.(PiN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient) /
N a, 12/20/22
Signature of0firdfied Well Contractor �' Date
6.Is(are)the weil(s): ©Permanent or ❑Temporary
B1'signing this form,I hereby certify that the we/f(s)was(were)constructed in accordance
with 15A 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 ENO copy ojthis record has been provided to ing well owner.
If this is a repair,fill out known well construction information and explain the nature ojthe
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: 200 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3 t@200'and 2(a3100) construction to the following: +
i
10.Static water level below top of casing: 19 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Centel,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of t11isi 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699.1636
Injection Wells:
13a.Yield(gpm) 20 Method of test: Air 24c.For Water Supply&Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount• 1/2 ib• 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