GW1--07590_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huns cuff 14.WATER ZONES i
Y FROM TO DESCRIPTION
Well Contractor Name. 215, ft 220 ft I 1 2 gpm
4070-A R. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(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)
FROM TO DLADIETER THICKNESS MATERIAL
2.Well Construction Permit#: 391703 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
DAgricultural ❑Municipal/Public fr. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18 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.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑StormwaterDrainage ft ft.
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hanluess,soil!,ock type.grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 6 ft. Red Dirt
7/6/23 . 6 ft 31 ft • Brown Dirt
4.Date Well(s)Completed: Well 1D#
31 ft 38 ft. Brown Rock.
5a.Well Location:
John Howell II 38 ft 400 ft Slate
• a.ft.
. Facility/Owner Name Facility ll)5(if applicable) '
Seams:58-61',65',69',81',90-94',
20959 Old Aquadale Rd, Albemarle 28001
-- I 98',215—2gpm
Physical Address.City,and.Zip 21.REMARKS
Stanly 142188 I ti ti, !L_-v aw/ ,—'`
County Parcel Identification No.(PIN) N O V 2 t 202
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i.
(if well field,one let/long is sufficient)
/ i/ IS1a ^.l 4 :y f :l.i
N W•
D /--. 71 ,,i- 4.7/25/23
Signature of edified Well Contractor Date
6.is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA 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 ii2l 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 iron-water supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 • (ft.) 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple was list all depths if different(example-3@200'and 2(4)100) construction to the following:
10.Static water level below top of casing: 36 (ff.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" " 1617 Mail Service Cent'er,,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For injection 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 WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 2 Method of test: Air 24a For Water Supply&Injection Wells:
13a.Yield(gpm) 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013