GW1-2022-10027_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt 14.WATER ZONES_
John W. E
FROM TO DESCRIPTION
Well Contractor Name `t-'. _; i'V y 54 fr. 60 ft 3 gpm
2465-A AA II ft ft.
NC Well Contractor Certification Number IY ll V O 2�22 15.OUTER CASING for multi-cased well's OR LINER if applicable)
nn
FROM TO DIAMETER THICKNESS 1 MATERIAL
Derry's Well Drilling, Inc. Inls, ram, , �ra� 4��urt►t 0 ft- 45 ft- 61/8 !"° SDR-21 PVC
Company Name D%AIQ/BOG 16.INNER CASING OR TUBING eothermal closed-loop)
118508 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: & & G in
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f6 ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 % 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 a licable
❑Aquifer Storage and Recovery l7Salinity Barrier FROM it TO MATEML EMPLACEMENT METHOD
i
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRrPTION color,hardness,soll/rock type,grain sim,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under/!21 Remarks) 0 tt 5 it Brown Dirt
5/5/22 5 n. 35 & Blue Slabs
4.Date Well(s)Completed: Well ID# 35 ft- 400 ff Slate
5a.Well Location: ft ft
Charles Garrison
ft ft
Facility/Owner Name Facility lD#(ifapplicable) ft it Seams:154'=3gpm,70',80', 115', 141%149,
32936 Rowland Rd., Albemarle 28001
ft. rt 190; 195',227',290',351',355'
Physical Address,City,and Zip 21.RFA7ARKS
Stanly 37212
County Parcel Identification No.(PIN)
I'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iallong is sufficient) �� //
N w Qey6p (i{/. I 5/31/22
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): 131'ermanent or ❑Temporary By signing this form,I hereby certify that,the well(s)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 0No copy ofthis record has been provided to 6,well owner.
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.
Far 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: 400 (fL) 24a. For All Wells: Submit this 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: 59 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of tliis'form within 30 days of completion of well
12.Well construction method: 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 276994636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Enviromnerrt and Natural Resources—Division of Water Resources Revised August 2013