GW1--01997_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES .FROM TO DESCRIPTION
Well Contractor Name 47 ft- 55 ft- 1 ' 2 gpm
4070-A 220 ft- 225 ft- I ; 18 gpm
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- 45 ft- 61/8 ;'. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
115598 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 4 in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) •
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN ' •
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it et in.
❑lndustriallCommercial ❑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. 1'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
FROM 'TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soilirock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 26 ft. Red Dirt
9/21/23 26 ft- 34 ft- Junky Rock
4.Date Well(s)Completed: Well ID# ft- ft-34 225 Gray Granite
5a.Well Location: ft. ft, 11 .
Tim Parker ft. ft. Seams:47-55'=2g,157-162',
Facility/Owner Name Facility ID#(if applicable)
ft. !, '
28708 HatleyFarm Rd,Albemarle 28001 ft It •
: 220'7,r. 18g
;
Physical Address,City,and Zip 21.1tFMAItKS - -'r h---I, Is. ld-,tl'„
y
Stanl 19142
APR a) 1 2024
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l n Or 22.Certification:
;r,-;;r.�:,'`.'t Pr7 :- K> ugh
(if well field,one lat/long is sufficient) i CiVr0f2(G
N W Z7GU &,L-., r' 10/15/23
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,1 hereby certifit that!lid,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 hlNo 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 I
9.Total well depth below land surface: 225 (fL) 24a. For All Wells: Submit this fom{ within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2®100' construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mall 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 fonn within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,IRaleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 20 Method of test: Air 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
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