GW1-2021-00844_Well Construction - GW1_20211208

k_
WELL CONSTRUCTTON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
John W. Huneycutt FR.WATER ZONES
PROM TO I DESCRIPTION
Well Contractor Name 115 ft 120 ft. 30 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a Ticable
FROM TO DIAMETER; T16Qfl11F.55 MATERIAL
Derry's Well Drilling, Inc. 0 ft. 68 fr 161/8 lin SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eotheimal closed-loop)
361750 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. Ir
List all applicable well permits(i.e.County,State,Variance•injection,etc.)
ft. B. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well• FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) fL m
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT-ME THOD&AMOUNT
❑irri ation 0 f" 3 n- Bent.Chips Gravity
Non-Water Supply Well:
3 fQ 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DL1Tt1tIA1. EMPLACEMENT METHOD
R ft.
❑Aquifer Test ❑Storrnwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soiUrock JyM grain sir,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 16 ft. Brown Dirt
4.Date Well(s)Completed: 9/1/21 Well iD# 16 ft. 46 ft. Brown Rock
46 ft 125 fL Blue Rock
Sa.Well Location: ft. ft
Bernice Sides ft. &
Facility/Owner Name Facility 1Dli(if applicable)
fL ft. Seams:85',95', 115'=30g
20089 Sam Rd, Albemarle 28001 ft. ft. �
�_ � ; _��•� •fir:-m 1! >,
Physical Address,City,and Zip 21.RFMARIsc
Stanly 21756 8
County Parcel identifieationNo.(PiN)
r,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: j`''
22.Certification:
(ifwell field one IaUlong is sufficient) Ij l (`rat al�i I;e}I } U �:'z WG UNi I
N W GtlLQrA 12/1/21
Si ot'Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,l hereby certify that the we/l(s)was(were)constructed in accordance
with 15A N(AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 0No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the i
repair under ell remarks section or on the back ojthis 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: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Par multiple wells list all depths ijdi,(jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing: 18 (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection 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 276994636
13a.]'field(gpm) 30 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 1013
i