GW1-2021-04505_Well Construction - GW1_20210429

4
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells e�
1.Well Contractor Information:
John W. Huneycutt � C�.� bj�� l4.WATER ZONES
_V r'� (� FROM TO DESCRIPTION
Well Contractor Name PQ Q<G pG 70 ft' 75 ft. ' 2 gpm (90'-95'=3 gpm)
2465-A ` �;`,o�Q�� 122 ft. 125 ft. 11 gpm (179'-185'=2 gpm)
NC Well Contractor Certification Number 15.OUTER CASING for multi cased sells OR LINER if a licable
rSQ FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 64 ft' 6 1/8 ! in. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
291477 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. in.
List all applicable well permits(i.e.County,State,Itariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 IL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 k. 35 rr• Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I MATERIAL. I 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 soiVrock typet gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 14 ft Red Dirt
1/21/21 14 ft• 42 ft• Brown Dirt
4.Date Well(s)Completed: Well ID# tt.
42 49 t[. Brown Rock
sa.Well Location: 49 rt. 200 rt. Granite Rock
Abby Kimrey
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams: 70'=2g,90'=3g, 122'=1 g, 130"
20956 Biles Rd., Albemarle 28001 ft. ft.
145', 158', 179'=2g
Physical Address,City,and Zip 21.REMARKS
Stanly 139616
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one IatAong is sufficient)
N W
. �GCyI,Q,i,�.l,G� 2/10/21
Signa6Ve of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this joint,I hereby cer-tifi,that the ur/1(s)it-as(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC102C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to th'e 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii erent(example-3C200'and 2C100') construction to the following:
10.Static water level below top of casing: 31 (ft-) Division of Water Resources,Information Processing Unit,
If,rater level is above casing,use"+ 1617 Mail Service Ce`ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of tliis 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.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) $ 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 Ib. 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