GW1-2023-01656_Well Construction - GW1_20230213

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WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ;
Dwight L. Huneycutt �o WATER ZONES'TO DESCRIPTION
Well Contractor Name n e � ' ��,^ 167 ft 170 f- i. 50 gpm
4070-A fj �' cr`� :r fL ft
F` n -,IS.OUTER CASING for multi-eased;iveus OR LINER if a livable
NC Well Contractor Certification Number In'"- v �(!�3 FROM TO DIAMETER THICtQ1FSS MATERIAL
Derry's Well Drilling, Inc. '" -�-�?r C/ 0 ft. 136 fL 61/8 SDR-21 PVC
16.INNER CASING OR TUBING eothermal closed-loop)
Company Name (/r;' FROM TO DIAMETER THICKNESS MATFurar.
2.Well Construction Permit#: 272421 ft. % is
List all applicable wellpermits Ii.e.County,State,Variance,injeclion,eta)
fL ft, li in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic fL ft. m.l
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in.'
❑lndustriaUCommercial ❑Residential Water Supply(shared) • 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 3 tr• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft. 20 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rentediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,sorllrocktype n sae,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 16 it. Red Clay
6/25/22 16 ff g ft. I Wet Brown Dirt
4.Date Well(s)Completed: fi
Well ID# 69 tr• 125 ft- Junky Brown Rock
5a.Well Location: 125 fL 185 ft. I' Slate
Matthew&Tiffany Ferrell fL f`
Facility/Owner Name Facility ID#(ifapplicable) ft ft. I'Seams:140-145', 150-154',
Shaver Rd, Albemarle 28001 fL 167-170'=50gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 35727
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lot/long is sufficient)
N W iT 1 .L 7/19/22
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this forob I hereby certify that the ivell(s)was fiver¢)constructed in accordance
with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofihis record has been provided to the well owner.
If this is a repair,Jill out known ivell 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 Ito 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 widr the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this!foim within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: 10 (il) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
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11.Borehole diameter: 6 (in,) 24b.For Injection Wells ONLY: IInjaddition to sending the form to the address in
Rotary 24a above, also submit a copy of this
ils form within 30 da`ys of completion of well
12.Well construction method: construction to the following:
(Le.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 27699-1636
13a.Yield(gpm) 50 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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