GW1--07580_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , k
.14.WATER ZONES ( L
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 91 ft- 94 ft' I 1 1 gpm
4070-A 156 fr. 159 ft 1{gpm (355-360'=2gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells).OR LLNER(if ap licable)
FROM TO DIAMETER! THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 50 It 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
366413 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
ft. ft. in-
❑Agricultural OMunicipal/Public .
ft❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft m
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 it Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 it Bentonite. Pumped
❑Monitoring ❑Recovery
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 ft ft.
❑Aquifer Test ❑Stormwater Drainage ,
ft. ft.
•
❑Experimental Technology ❑Subsidence Control , 20.DRILLING LOG(attach additional sheets if necessary) .
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.) .
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft. 7 ft Brown Dirt
4.Date Well(s)Completed: 4/5/23 Well ID# 7 ft. 16 it •
Brown Rock
16 ft 425 ft Slate
5a.Well Location: ft. ft. '
Mark Hartsell ft. ft. ,
•
Facility/Owner Name Facility ID#(if applicable)
29079 Jordans Pond Dr., Albemarle 28001 ft ft Seams:59',76',91'=1gpm, 156'=1gpm,
ft. ft. 347',355'=2gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 31207 4 . ,-
County Parcel Identification No.(PIN) t'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: NOV o V 2 r 1013
22.Certification:
(if well field,one lat/long is sufficient) • // I,p I _ �.1, 'r_.
N W pG(t� ,C.. # t},,.,.,.., `_;�5/1J23:,;i
Signature of ertified Well Contractor "bate
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that:the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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 I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 425 (ft.) 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:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 36 (ft)
Ifwater level is above casing,use"+" 1617 Mail Service i 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.) i
Division of Water Resources,Underground Injection Control Program, ,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 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