GW1-2021-04504_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:
Huneycutt y 14.WATER ZONES
John W. Hune
Y ROM TO DESCRIPTION
Well Contractor Name O� 225 ft 235 ff p 15 gpm
2465-A �� deb
NC Well Contractor Certification Number �� -1G gG�` 15.OUTER CASING for multi cased wells OR LINER i[a livable
DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. �'�yJQ' o rL s� ft. s 1/8 i" 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loo
275721 \� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ' in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation p rL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 e. 35 rc. Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO I 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 necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gnin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 ft' 10 tt. Red Dirt
2/3/21 10 e. 39 h Brown Dirt
4.Date Well(s)Completed: Well ID#
39 51 fc Brown Rock
5a.Well Location:
51 tc• 265 tc• Blue Rock
Zach Chilton rc. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
rc. rc. Seams: 89', 119', 179',225'=15g
Harkey Rd, Albemarle 28001
Physical Address,City,and Zip
21.REMARKS
Stanly 139387
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /
N w Illy (�(� � 2/15/21
Si ure of Certified Well ContractoriV Date
6.is(are)the well(s): (OPermanent or ❑Temporary BY signing this forth,I hereby certify that the u•ell(s),vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC42C.0200 Well Construction Standards and that a
i
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to th'e well o,vner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 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-,eater supply,vells ONLY,rith the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,cells list all depths if di-(jerent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing:
21 (ft.) Division of Water Resources,Information Processing Unit,
If ureter level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test: Air
24c.For Water Supply&Injection iWells:
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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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