GW1--04994_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES I
— .r,.;S F."F`3 FROM TO DESCRIPTION'
Well Contractor Name t.; C.IIi.p 104 ft- 106 ft- 1 gpm
2465-A Q AUG20 ft- 330 ft- 29 gpm
G
NC Well Contractor Certification Number A U 0 1 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. �,s,. ;r, c ��' o ft- 57 ft- 61/8 is SDR-21 PVC
a- Dv `2'4'^' 16.INNER CASING OR TUBING
Company Name (geothermal closed-loop)
378449 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. ft. ' in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public H. ft. in
ft f in.❑Geothermal((Heating/Cooling Supply) OResidential Water Supply(single)
0 Industrial/Commercial ❑Residential Water Supply(shared) 18. ROUT
FROMG TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. 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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test OStormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Red Dirt
2/3/23 5 ft- 25 ft- Brown Dirt
4.Date WeB(s)Completed: Well ID# _ .
25 ft- 40 n• Brown Rock
5a.Well Location: 40 ft- 345 ft- Blue Rock
Joshua Cole
Facility/Owner Name Facility ID/1(if applicable) •-
ft. ft: Seams:83',93', 104'=1gpm, 139', 150',
28776 Flint Ridge Rd, Albemarle 28001 ft. ft. 168',215',320'=29gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 141483
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 Wgoifrp Lt/. 2/28/23
Si afore of Certified Well Contracto Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this fora,I hereby certify that the wells)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the 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.
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: 345 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 19 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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