GW1--05005_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.WATERZONES-
Y FROM TO DESCRIPTION
Well Contractor Name r. ,,,, *i 110 ft 117 ft 5 gpm
2465-A VI.'Z".—" ..r'' D 249 ft. 252 ft 1 ! 5 gpm
NC Well Contractor Certification Number AUG G 0 1 7 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft 61/8 SDR-21 PVC
Company Name IfliCi�''`A").,:'t ° '"�"'""'"" ur�A 16.INNER CASING OR TUBING(geothermal closed-loop)
I::':v,/ i k3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 376460 ft ft in.
List all applicable well permits(i.e.County,Stale,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 OMunicipal/Public ft. ft in.
❑Geotheal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in.
rm
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ' it 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)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier t. ft.
❑Aquifer Test ❑Stormwater Drainage ,
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc-)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 8 ft Red Dirt
4.Date Well(s)Completed: 11/17/22 Well ID# 8 ft 265 ft Blue Rock
ft. ft.
Sa.Well Location: ft. ft.
Jacob Corner fr. ft.
Facility/Owner Name Facility ID#(if applicable)
ft ft Seams: 110'=5gpm,249'=5gpm
Prospect Church Rd, Albemarle 28001
ft ft.
Physical Address,City,and Zip 21,REMARKS
Stanly 3883
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) g.d;i
N W i a). 12/3/22
Siagature of Certified Well Contract° Date
6.Is(are)the well(s): 127Permanent or ❑Temporary By signing this form,I hereby cert/that the well(s)was(were)constructed in accordance
with 15A 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 IZINo 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 1121 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 Mail Service Center,Raleigh,NC 27699-1636
10 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resouri es Revised August 2013