GW1--02012_Well Construction - GW1_20240401

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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 cuff 14.WATERZONES ( .
g Y FROM TO DESCRIPTION
Well Contractor Name 117 ft- 122 ft. I , 20 gpm .
4070-A 128 ft- 130 ft 1 ' 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- 106 ft- 61/8 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
365853 FROM TO DIAMETER, . THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
ft. ft. Lin'
3.Well Use(check well use): 17.SCREEN
Water.Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
:Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ZiResidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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❑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) •
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 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,sail/rock type,grain sirt,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 25 rt. Red Dirt
4/21/23 25 ft- ft- Brown Dirt
4.Date Well(s)Completed: Well MN
54 ft. 95 ft- ; Brown Granite
5a.Well Location: _ 95 ft. 145 ft- ;, Blue Granite
Clayton Homes
ft. ft. 1 '
Facility/Owner Name Facility IDN(if applicable)
ft. ft - Seams:110', 117'=20g,128'=log
Gold Branch Rd, Salisbury 28146 ft , ft.
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Physical Address,City,and Zip 21.REMARKS I I; -',17-' q ,i tiM ,
Stanly 417 144 i , t <•a.....,t s L.Li
County Parcel Identification No.(PIN)
!, A f1R 4 1 2021
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /' lfliv;it a%'^Ilia, ! ,�^•:-
D L. ��/123n
N W
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Signature of ertified Well Contractor. Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certiry that jthe well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA 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 1t21 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 I
9.Total well depth below land surface: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100' ' construction to the following:
10.Static water level below top of Lasing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Colter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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)
30 Method of test: Air 24c.For Water Supply&Injection Wells:
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Also submit one copy of this form 1within 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