GW1-2023-01736_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Ilse ONLY
This form can be used for single or multiple wells
1.Well[Contractor Information:
Dwi ht L. Hune�/cuff 14•WATER ZONES
9 FROM TO DESCRIPTION
Well Contractor Name 236 ft- 242 ft- 5 gpm
4070-A '-M ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wels OR LINER if a ble
�(1�� FROM TO DIAMETER TFIICFINESS MA't'F,R1 1.
Dery's Well Drilling, Inc. FEB`B l� 0 ft 140 f 61/8 SDR-21 I PVC
Company Name ;^- 1 -- 16.IN NER CASING OR TURING eothermatclosed-loo
r�(w�r ��q FROM TO DIAMETER TRICKINESS Mkl"ERIA1.
2.Well Construction Permit 11: 202VwV5"'V e'la); 3
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.)
fr. ft. io.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATFAIAL
❑Agricultural ❑Municipal/Public fr. ft. in
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GRO1Tr
FROM TO MATERIAL EMPLACEMENT METHOD tk AMOUNT
DIrrigation
Non-Water Supply Well: 0 ft 3 Bent Chips Gravity
❑Monitoring ❑Recovery 3 fL 20 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACs if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. rt.
❑Aquifer Test ❑Storrnwater Drainage
tr. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if oecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock a grain siu rtc.
❑Geothermal satin Coolin Rehm ❑Other lain under k21 Remarks 0 ft. 8 ft. Red Clay
11/8/22 8 fL 127 ft. Brown Dirt
4.Date Well(a)Completed: Well]IDt✓ 127 ft- 300 ft- Blue Granite
53.Well Location: ry fL
Buddy Ball ft. fL
Facility/OwnerName Facility ED#(if applicable) ft. rL Seams: 145', 159', 170', 197',236'=5gpm
1332 Spanish Dr., Asheboro 27205 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Randolph 7649267150
County Parcel Ideffification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification:
(if well field,one[at/long is sufficient)
N W r�w 11/15/22
Signature oftertifted Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this 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 421 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 cons&uc&n,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 40 (n-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter• 6 On.) 24b.For Infection 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 27699-16M
13a.Yield(gpm) 5 Method of teat: 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.
I-ono GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2011