GW1-2023-02721_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Dwight L. Hune curt FRO51 ER ZONES
Dwi
9 Y FROM TO DESCRIPTION
Well Contractor Name EE
i 372 ft 377 2gpm
4070-A p (� ] ft fL
NC Well Contractor Certification Number APR I j 2023 15.OUTER CASING formutti-casedweM ORI.INER ifa licable
FROM TO DIAMETER THIC[CNFSS MATERIAL
Derry's Well Drilling, Inc. �; M ,� „ ; Unit 0 ft- 1103 R- 61/8 � ' SDR-21 I PVC
Company Name ~,�;'d(1 (?i� 16.iNNER CASING OR TUBING(geothermal closed-loop)
2021-00003377 FROM I To I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in
I,lsr ail applicable well permits(i.e.County,Siaie,Variance.Injection,etc.)
ft ft. in.
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: FROM TO DL111fETER SLOT SIZE TEXIO ESS MATERLAL
ft. ff. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it in
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACENIFNT METHOD&ANIOUNT
❑irrigation 0' ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 &it- 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft tL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
FROM TO DL1 EIIIPLACE1tiEN'f hIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier T17tIAL
ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft:
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,haudnes&sottfroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 21 ft Red Dirt
4.Date Wells)Completed: 2/13/23 Well ID# 21 & 67 ft. Brown Sandy Dirt
67 & 82 & Brown Granite
5a.Well Location: 82 f` 445 ft- Blue Granite
Vance T. Lavery ft.
Seams:129', 137', 152', 175',228',233',
Facility/Owner Name Facility JD#(ifapplicable)
ft. fL 241',277',336-348',372-377'=2gpm
2863 Glowing Wood Trail, Asheboro 27205 ft. &
Physical Address,City,and Zip 21.REMARKS
Randolph 7791072539
County Parcel identification No.(Pill
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcU field,one lat/long is sufficient)
N R, Z_Iwe 3/10/23
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)teas(were)constructed in accordance
with 15A NCAC 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 ofthis record has been provided to the we//owner.
if this is a repair,j//oul 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 bgectlon or non-water supply ire/Is ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 49 (ft.) Division of Rater Resources,Information Processing Unit,
If water 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 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) 2 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 Ib. well construction to the county health department of the county where
constructed.
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Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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