GW1--05008_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: ,
.14.WATER ZONES -
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name ; i—. •e\/ 'F G µit 336 ft 345 ft ; 20 gpm
4070-A ft n
NC Well Contractor Certification Number Aii G a 7 2023 la-OUTER CASING(for multi-cased wells)OR LINER(if ap licable) ,
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. _^q` ��U o ft 45 ft 6 1/8 SDR-21 PVC
i1*�% .Y:'rt` c' 16.INNER CASING OR TUBING(geothermal closed-loop)
t Company Name 379714 a414w.eT� .ra FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. iu.
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
ft. ft. in.
:Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM 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 ❑GroundwaterRemediation .19.SAND/GRAVEI;PACK.(if applicable)-
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
:Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control 20.13RILLING LOG(attach additional sheets if necessary)' -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiliroek type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft 9 ft. Red Dirt
3/29/23 9 ft 21 ft ' .Brown Dirt/Rock
4.Date Well(s)Completed: Well 1D#
21 ft 365 ft • Slate
5a.Well Location: ft. ft.
Charles Parnell
n ft. Seams:56',78',222',250',336'=20gpm
Facility/Owner Name Facility ID#(if applicable)
ft ft
NC 73 Hwy, Albemarle 28001 ft. ft.
Physical Address,City,and Zip 21'.REMARKS
Stanly 12091
County Parcel identification No.(PiN)
511 Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N • W t-L 7 r 4/30/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certh 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.Ts this a repair to an existing well: ❑Yes or EINo 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
S.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: 365 (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@1001 construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 29 (ft)
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
13a.Yield m 20 Method of test Air 24c.For Water Supply&Injection Wells:
(gp ) 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013