GW1--05137_Well Construction - GW1_20240830

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 58 ft• 60 ft- 2 gpm (169-174'=2 gpm)
4070-A 243 ft 247 ft 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap • ble)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 44 ft61/8 I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
398552 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) ft.ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic it• ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply ft. ft. in.
( B� B PP Y) PP Y
❑Industrial/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 it-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery [Salinity Ranier PROM TO MATERIAL EMPLACEMENT METHOD
tt. ft
DAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer PROM TO DESCRIPTION(color,hardness,soil/rock type,grain sine,etc_)
[Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft 12 ft Brown Dirt&Rock
4.Date Well(s)Completed: 3/4/24 Well I 12 ft• 300 ft Slate
D#
ft. ft.
5a.Well Location: rt. ft.
Stephanie&Thomas Brown
I� ft. ft. Seams:48',55',58'=2g,69',74',83',
Facility/Owner Name Facility UN(if applicable) ft. ft. 134', 169'=2g,243-247'=3g
20300 Union Grove Rd., Albemarle 28001 tL ft
Physical Address,City,and Zip 21.REMARKS (: • •'
Stanly 140301 • t,—. •. - .4-
County Parcel Identification No.(PIN) AUG I G J /24
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: li V tl 0 Cj� i
(if well field,one lat/long is sufficient) ! ' - ,__'-:,.N." •. I.),,
N W Z7t,f.fr :eyA-.Z.... yi/u7catt- DAF9Jzt--
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Ca Permanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A 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: 300 (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:
10.Static water level below top of easing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection 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) 7 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013