GW1-2023-01664_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. Hume cuff 14.WATER ZONES b I
g FROM TO DESCRH710N
Weu Contractor Name 267 ft. 269 ft' I 5 gpm
NC Well Contractor Certification Number L p ���� 15.OUTER CASING for multi-cased wells'OR LINER if a licable
F t B 1 FROM TO DIAMETER THICI�IFSS MATERIAL
Derry's Well Drilling, Inc. o ft 45 fr. 6 1/8 'n•,` SDR-21 PVC
rtits'"`;Y* t'1 v y A•a, Un 16.INNER CASING OR TUBING eothermal closed-loop)
Company Name rt..� n; � 1
116913 '�'�° FROM TO DIAMETER+. THI EENESs MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(t.e.County,State,Variance,Injection,etc.) '
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLUMfETER SLOT SIZE THICHNnS MATERUL
❑Agricultural ❑ %Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irri 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 OGroundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM f4 To ft. DLITERIAL I, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soitlrack e n sve etc
❑Geothermal eating/Cooling Return) 170ther(explain under#21 Remarks) 0 ft- 32 ft. Brown Dirt Rock
1/26/22 32 fL 300 ft. i Slate
4.Date Well(s)Completed:• Well ID#
ft ff. i
5a.Well Location: ft ft
Barry McSwain & M
Facility/Owner Name Facility ID#(if applicable)
ft. ft Seams:54,58',87%98% 170', 193',238'
39108 Boone Caudle Rd., Norwood 28128
f6 iG i, 267'=5gpm,270'
Physical Address,City,and Zip 21.REl11ARKS
Stanly .29140
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County Parcel Identification No.(PIN)
5b.Latltude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one lat/long is sufficient)
N W 2/15/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 101ermanent or ❑Temporary By signing this form,I,hereby certify that the wells)was(were)constructed in accordance
with IBA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: QYes 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 ofthis 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: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3(200'and 2@100) construction to the following:
10.Static water.level below top of casing: 32 (10 Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 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) 5 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfectiontype: Granular Amount: 1/2 lb. well construction to the county health department of the countywhere
constructed.
Farm GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resourcesl Revised August 2013
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