GW1--05041_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name 133 ft- 140 ft- 4 gpm (147-154'=4 gpm)
4070-A 305 ft- 310 ft- 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 93 ft' 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
8 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit# 407778 8 ft ft in.
List all applicable well permits(i.e.Counry,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
❑Agricultural OMunicipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ft ft m
❑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.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
—
ft. D.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sing etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 31 ft. Brown Dirt
4.Date Well(s)Completed: 6/21/24 Well HMI
ft Brown Rock
77 ft-
77 n 325 ft- Slate
5a.Well Location: R. ft.
Matthew& Rachel Carter
Seams: 128', 133'=4g, 147-154'=4g,
Facility/Owner Name Facility iD#(if applicable)
f
33232 Mann Rd., Albemarle 28001 ft. ft. 158',270',3o5'=4g
ft
Physical Address,City,and Zip 21.REMARKS
Stanly 15972 •/ 3
County Parcel identification No.(PIN) A Ut n
� 0 1.424
5b.Latitude and Longitude in degrees/ntiuutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) l f'f;":-..;' : .'r-:^,Nr. - .
N W
Z2w L � Gu `6/24/24 '
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form 1 hereby certify that the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is 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
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: 325 (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@100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a 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
13a.Yield(gpm) 12 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