GW1-2021-04500_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Dwight L. Huneycutt �� ���'� J�~� FROWMATERzO DESCRIPTION
Well Contractor Name 190 ft 196 150gpm
4070-A �� Q�R' �oo� �o� rt ft.
V. 15.OUTER CASING for multi-cased wells OR LINER "'applicable
NC Well Contractor Certification Number �,Q-� FROM TO DIAMETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. ��q'S 0 49 n 6 1/8 SDR-21 PVC
Company Name ��. 16.INNER CASING OR TUBING eothermat closed400
274605 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit th fL fL in•
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic % ft. ins
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lari ation 0 fL 3 D• Bent.Chips Gravity
Non-Water Supply Well:
3 fL35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: % h'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL fL
❑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 Ccolor,hardness,soWrock type,Cmin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n• 6 M Red Clay
4.Date Well(s)Completed: 11/2/20 Well ID# 6 'L 16 M Brown Dirt&Rook
16 f• 200 fL Slate
58.Well Location: g• fL
Dwight Eudy ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL Sea MI s: 50',59-70',90', 121', 150', 177',
Tom Rd., Albemarle 28001
ft. n• 190'=150g
Physical Address,City,and Zip 21 REMARKS
Stanly 7389
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:well field,one lat/long is sufficient) /
N W . 11/28/20
Signature oYCertified Well Contractor j Date
6.I9(are)the well(s): OPermanent Or ❑Temporary By signing this form,I hereby certify that the wells)was(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 91No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200 (ft) 24a. For All Wells: Submit thi I s form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (n•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 150 Method of test: Air
24c.For Water Supply&Injecti Ion 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 ticalth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources--Division of WaterlResources Revised August 2013