GW1--02002_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ! I
1.Well Contractor Information: IV
DWI ht L. Hung cutt 14.WATER ZONES i
y Y FROM TO DESCRIPTION
Well Contractor Name 250 ft 255 ft 1 gpm
4070-A ft ft 1
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. 0 ft 44 ft- 61/8 tit SDR-21 PVC ,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
371962 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(Le.County,State,Variance,Injection,etc.)
ft. ft. ' in.
3.Well Use(check well use): 17;SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft in
ft ft. in.
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)❑lndustrial/Commercial ❑Residential Water Supply(shared) 1s.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft 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) •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 14 ft ' Brown Dirt&Rock
10/2/23 14 ft 19 ft Slate
4.Date Well(s)Completed: Well ID# 19 ft 27 ft. Brown Dirt
sa.Well Location: 27 ft 500 ft ! Blue Granite
Venture 8 Property Experts ft. ft. Seams:52',68',81', 129', 150',211',
Facility/Owner Name Facility!DWI(if applicable) ft ft 254'-Ica,433' 49,E
Coyle Rd., Stanfield 28163
Physical Address,City,and Zip ft. f t 1 `a k"i.. V I_j ')
21.REMARKS i
. Stanly 137646 APR t) 1 2024
County ' Parcel identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: D WCt 3'DQ
(if well field,one lat/long is sufficient)
N W �/�.L ' 10/21/23
Signature of Certified Well Contractor 1 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 1SA 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 allo copy of this record lies been provided to the ivell 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
8.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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
500 '
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion,of well
For multiple wells list all depths tfdijjerent(example-3 a(200'and 2 a@100' construction to the following:
10.Static water level below top of casing: 30 •(f.) Division of,Water Resources,Information Processing Unit,
Ifseater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gp•
m) 1 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