GW1-2021-04499_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
John W. Huneycutt `4 _ WATERzONES
��..ii RROM TO I DESCRIPTION
Well Contractor Name �� �`& 83 fL 87 ft 40gpm
2465-A �� �t�0 �p1` ft. ft.
NC Well Contractor Certification Number / Q Zyg`� 15.OUTER CASING for multi-rased wells OR LINER tf s 6cable
C �Q FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. QQ QcC, 0 ft 158 ft 6 1/8 in SDR-21 I PVC
Company Name ��Q� 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATE UA
2.Well Construction Permit#: 329312 0 fL ft• in.
List all applicable well permits(i.e.County,State,Variance, ction,etc.)
ft. ft, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL fL in.
❑Agricultural ❑MunicipaUPublic
[]Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑R�cey 3 35 Bentonite Pumped
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑ FROM Aquifer Storage and Recovery ❑Salinity Barrier fLTO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater DrainagefL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,min: etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 12 fL Brown Dirt
1/18/21 12 ft 26 fr Brown Rock
4.Date Well(s)Completed: Well ID#
26 fL 105 ft. Slate
5a.Well Location: ft. &
Bernice Guy Almond Jr ft. ft.
Facility/Owner Name Facility ID#(if applicable)
30905 John Deere Dr., Albemarle 28001 ft. ft. Seams: 69',83'=40gfL ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 138630
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W � r t 2/8/21
Signature 61 Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)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 allo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out brown well construction information and explain the nature ofthe
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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3©200'and 2@100) construction to the following:
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
Ifwater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) 40 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form`within 30 days of completion of
136.Disinfection type:
Granular Amount: 112 lb.
well construction to the county hcalth department of the courtly where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water i asources Revised August 2013