GW1-2023-02674_Well Construction - GW1_20230411

i
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
g Y FROM TO DESCRIPTION
Well Contractor Name 277 fL 290 ft' 10gpm
4070-A _ ft. ft
NC Well Contractor Certification Number 15.OUTER CAS WG for multi-cased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS' MATERIAL
Derry's Well Drilling, Inc. APR 1 1 2023 0 ft 44 ft 6 1/8 ' soR-21 Pvc
Company Name 16.INNER CASING OR TUBING eothermal closed-loon)
375296 ';,;._..;, ,:,.."1 ;1:;:4i !JI-,i FROM TO DIAMETER THICKESS N MATERIAL
2.Well Constriction Perndt#: !:{"; '<'1; ft. fL in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. fi. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
in
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ClIrrigation 0 M 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 It. 20 ft Bentonite Pumped
Injection Well: fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. fL To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIMON color,hardness,saflinck type,grain rat,etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Emaj 0 ft. 6 ft Red Dirt
9/14/22 6 ft 23 It. Brown Dirt Rock
4.Date Wells)Completed: Well ID# 23 ft 500 ft. Slate
5a.Well Location: ft. ft.
MPH Land LLC
fr. fL Seams:62';78', 150', 165', 170',210',
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 248',277'=10gpm
Old Davis Rd, Norwood 28128 ft. ft.
Physical Address,City,and Zip 21.RFAfARKS
Stanly 24396
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcU field,one Wong is sufficient)
N W . J ' 10/1/22
Signature o Certified Well Contractor Date
6.Is(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 ISA NCAC 02C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fll out known well construction information and explain the nature ofthe
repair under k21 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 ofweUs constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple ii jection or non-water supply ivells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a 200'and 1Q100) construction to the following:
10.Static water level below top of easing: 38 (ft.) 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 (in.) 24b.For injection 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
13s.Yield(gpm)
Q 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: 112 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Emiroument and Natural Resources—Division of Water Resources) Revised August 2013