GW1-2023-01662_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:
DWI ht L.. Hune`/cuff 14.WATER ZONES
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9 7 s 's'' , FROM TO I DESCRIPTION
Well Contractor Name V 70 ft 76 ft. I I 110gpm
4070-A ft ft. f
NC Well Contractor Certification Number FEB�� �`23 15.OUTER CASING for multi cased wells OR LINER if a Gcable
FROM TO DNMETER i THIC[QIESS MATERIAL
Derry's Well Drilling, Inc.In'"'r`''r�t- ='r4^c ,� tl:f o 46 ft 61/8 �' t° SDR-21 PVC
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Company Name '
``U C't'jt 7 16.INNER CASING OR TUBING sothermal closed-loop)
367760 FROM TO DIAMETER TDIC[01E.SS MATERIAL
2.Well Construction Permit#: ft ft. �! is
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.l
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f fl 1°
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri anon Non-Water Supply Well: 0 ft' 3 ft. Bent.Chips Gravity
[]Monitoring ❑Recovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft I•
❑Aquifer Recharge ❑Groundwater Remediation "19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IHATERLIL ' EMPLACEMENT METHOD
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,saiurock typr,grain six,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 g, 4 ft ! FIII Dirt
5/9/22 4 ft. 11 ft. Brown Dirt Rock
4.Date Well(s)Completed: Well ID#
11 ft 145 ft Slate
5a.Well Location: ft ft
Abelardo Espinoza Valdovinos rr. rt
Facility/Owner Name Facility ID#(ifapplicable) ft Seams:50',55',70-76'=110gpm
20426 NC 138 Hwy, Albemarle 28001 iL ft
Physical Address,City,and Zip 21.REMARKS
Stanly 21287
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwcll field,one latAong is sufficient)
N q, 5/25/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well 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 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 INSTUCTIONS
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9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 15 (fG) 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 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) 110 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
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