GW1-2021-05807_Well Construction - GW1_20210709

k
k
WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wills
1.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES
g J FROM TO DESCRIPTION
Well Contractor Name 172 ft' 175 f 3 gpm
4070-A 1 1 g 2p21 274 fit- 280 fit- 3 gpm
NC Well Contractor Certification Number J U L 15.OUTER CASING for multi-cased wells OR LINER ifa l cable
Unit FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. t fooessing o ft. 70 ft. 61/8 i" SDR-21 I PVC
Company Name `t V`^I e v' 16.INNER CASING OR TUBINGfgeotherntal close&too
273083 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. rt. In.
List all applicable well permits(t,e.County,State,Variance,Injection,etc.)
rt. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM I TO MATERIAL. -EMPLACEMENT METHOD&AMOUNT
❑trri ation 0 h• 3 R• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft Bentonite Pumped
injection wen: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑ FROM TO Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. MATERWL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if nmessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soft/rock tyM grain sae etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft 5 ft. Fill Dirt
3/29/21 5 ft 19 ft. Brown Dirt
4.Date Well(s)Completed: Well 1D#
19 fi- 57 ft. Brown Rock
Sa.Well Location: 57 ft 325 ft. Slate
Roger Laton & ft.
Facility/Owner Name Facility ID#(if applicable)
rt ft Seams: 109', 155', 172'=3g,274'=3g
48134 Access Dr., Albemarle 28001 ft. ft
Physical Address,City,and Zip
21.REMARKS
Stanly 14488
Comity Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one hit/long is sufficient)
N w 4/15/21
Signature of Certified Well Contractor V Date
6.Is(are)the wen(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the wel!(s)was(were)constructed in accordance
with 15A NCAC 02C.0i00 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or END 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 r11 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.
Nor multiple injection or non-water supply wells ONLY with the same consbructiam you can
submit oneform. SUBMITTAL iNSTUC'"ONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdtfferent(example-3@200'and 2@I001) construction to the following:
10.Static water level below top of casing 48 (fi) Division of Water Resources,information Processing Unit,
04mer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
r
11.Borehole diameter. 6 (in.) 24b.For injection Wells ONLY: 'In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Wen construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 6 Method oftest• 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources ` Revised August 2013
s
fr
i