GW1--07560_Well Construction - GW1_20231121

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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. Hune cutt 14.WATER ZONES. 1
g Y FROM TO DESCRIPTIONI
Well Contractor Name 122 ft 125 ft I I 5 gpm
4070-A 150 ft 160 ft J ' 10 gpm
NC Well Contractor Certification Number '15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 92 ft 61/8 aln SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00001096 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.) ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultu al ❑Municipal/Public ft. to
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity Non-Water Supply Supply Well:
OMonitoring ORecovery 3 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft '
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 22 , ft Red Dirt
22 ,4.Date Well(s)Completed: 6/26/23 Well ID# ft 68 ft Brown Dirt
68 ft 122 ft Brown Granite
5a.Well Location: 122 ft 185 ft Blue Granite
Garrett Brewer ft.
Facility/OrmerName Facility ID#(if applicable) ft ft Seams:107', 114', 122'=5gpm, 150'=10gpm,
3596 Osborn Mill Rd, Asheboro 27205 ft. ft. 175'
Physical Address,City,and Zip 21.REiitARKS
Randolph 7698146137 . , -
County Parcel Identification No.(PIN) . 9
.n 'Iy dam,,,Q M
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: N O V 2 j 2023
(if well field,one lat/long is sufficient) L.
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N W 17 :7n %7/.1.812,3:;''I Liwl:
SignatureWell Contractor LJ:e Datei Ji,-;
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certtry[hal,the well(s)was(were)constructed in accordance
with 15,4 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 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#21 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 of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non=watersupply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS j
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3( 200'and 2@100') construction to the following: I.
10.Static water level below top of casing: 30 (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 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: rY 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) 15 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 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013