GW1--05147_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 91 ft. 94 ft- 3 gpm
4070-A 116 ft- 120 ft- 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft- 6 1/8 in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
399123 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
❑Agricultural ❑Municipal/Public ft. H. in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft,
ft. in.
❑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. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicab)
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)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Wet Brown Dirt
4.Date Well(s)Completed: 4/8/24 Well ID# 5 ft. 23 ft Brown Dirt
23 ft- 32 ft. Brown Rock&Quartz
Sa.Well Location: 32 ft- 265 ft Slate
Richard Wells ft. ft• Seams: 51',66', 75',91-94'=3g, 116'=3g
Facility/Owner Name Facility iD#(if applicable)
ft. ft.
24270 Mini Airport Rd., Albemarle 28001 ft. ft.
Physical Address,City,and Zip ` , ,: •
21.REMARKS
Stanly 33727 AUG ;,
1- 24
County Parcel Identification No.(PiN)
7
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: I-),.'. + , J,-;
(if well field,one lat/long is sufficient) 22.Certification:
N w .c.-. 4/25/24
Signature of trertified Well Contractor Date
6.is(are)the well(s): LaPermanent or ❑Temporay By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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: 265 (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 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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