GW1-2023-02700_Well Construction - GW1_20230411

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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:
John W. Hume cuff 14.WATER ZONES i
Y FROM TO DESCRIPTION
Well Contractor Name 105 f- 109 fr' 3 gpm
2465-A _ 186 a 190 fL 2 gpm
NC Well Contractor Certification Number ;T n^"` "5 15.OUTER CASING(tor multi-cased wells'OR LINER if a Gcable
� f•;j"T 1 ' FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc., 0 fL 66 ft. 6 1/8 SDR-21 I PVC
Company Name _ 2un 16.INNER CASING OR TUBING(eothermal closed-loop)
374755 FROM To DL43 ETER THICKNESS MATERIAL
Z.Well Construction Permit#: ft. fr. in.
List all applicable ivell permits r.e.County, In State,Variance, ectiy, 'etc.. _,..,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIDVFSS MATERLAL
❑Agricultural ❑Municipal/Public ft. fL in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri anon 0 ft' 3 ft Bent.Chips Gravity
Non Water Supply Well: 3 tc. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ftTo MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
fL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if recess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soWrockt nsizeetq)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft Red Dirt
7/26/22 10 ft 36 ft Brown Dirt
4.Date Well(s)Completed: Well 1D#
36 ft 205 ft Blue Rock
5a.Well Location: ft ft
Myron E. Lowder a.
Seams:69',77',84', 105-109'=39pm,
Facitty/Owner Name Facility IDII(if applicable)
tL tL 130', 186'=2gpm
20935 NC 73 Hwy, Albemarle 28001
ft ft
Physical Address.City,mid Zip 21.REMARKS
Stanly 15732
County Parcel ldentlficationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcH field,one lat/long is sufficient)
N W 8/10/22
Sign re of Cettified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby cerlify that the ivell(s)teas(were)constructed in accordance
ivith I5A MCA 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy of this record has been provided to the well owner.
iftlris is a repair,fill out known well construction information and erplain the nature ofthe
repair under tt21 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 no»-water supply tveliv ONLY mith the same construction,you can
submit one form. SUBMPfTAL INSTUCI'IONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(e ample-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
If tvaler level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For lniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this farm within 30 days of completion of.veil
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&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amounh 1/2 lb. Well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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