GW1-2021-04501_Well Construction - GW1_20210429

p�
WELL CONSTRUCTION RECORD . �►°' For Internal Use ONLY:
This form can be used for single or multiple wells �� ^
1.Well Contractor Information:
John W. Huneycutt �� 1. WATER ZONES
v Cj�� FROM TO DESCRIPTION
Well Contractor Name Q —Q(OC'QG�13 96 f`• 100 f` 1 gpm
2465-A 3.0,�S$ 247 f` 250 f` 1 gpm
( � IS.OUTER CASING for multi cased wells OR LINER if a livable
NC Well Contractor Certification Number \�j�� o FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 I'L 170 ft- 61/8 `1O SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
305250 FROM TO DIAMETER THICKNESS -MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well permits(i.e.Counn,,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
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft. 3 rL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f` 35 e• Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ticable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft. i
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 18 ft. I Red Dirt
f` f` Brown Dirt
4.Date Well(s)Completed: 1/21/21 18 58
Well ID#
58 f` 63 f` Brown Rock
5a.Well Location:
63 f` 360 f` Granite Rock
Cody Evonsion ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Seams: 87',96'=1g, 122', 150',247'=1g
Flint Ridge Rd., Albemarle 28001 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 27944
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one W/long is sufficient)
N W 2/10/21
Si ture of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,1 hereby certifi•that the wells),vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15.4 NCAC:01C.0200 Well Consir-rrction Standards and that o
7.Is this a repair to an existing well: ❑Yes or FIND copy ofthis record has been provided to the uell owner.
If this is a repair,fill out knoum ivell construction it formation and explain the nature of the
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 samre construction,you can
submit oneform. SUBMITTAL 1NSTUCTIONS
r
9.Total well depth below land surface: 360 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths if eli ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:
38 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gpm) 2 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. I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i