GW1-2022-03889_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information-
Dwight L. Huneycutt DWI14.WATER ZONES 1
9FROM TO DESCRIPTION
Well Contractor Name 215 fL 222 ft. 1 5 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASiNG for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THI/7QdESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 50 ft 6 1/8 , in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotherma!closed-lox
117291 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(t.e.County,State,Variance,Injection,etc.) ft. T
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THI S
❑Agricultural ❑Municipal/Public ft. ft m
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑iri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATERIAL EMPLACEMENT METHOD
tt.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color.hardness,soiltrock tym lgrain shm,do
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 IL 28 ft Brown Dirt
10/5/21 28 fL 40 ft. Brown Rock
4.Date Well(s)Completed: Well iD#
40 ft- 245 rt• Slate
5a.Well location: ft. ft.
Bill Hatley ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. fl Seams: 62',97', 116', 136', 175',215'=5g
31965 Old Herlocker Rd., Albemarle 28001 ft. ft.
Physical Address,City.and Zip 21 REMARKS
Stanly 31078
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degreestminutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one lat/long is sufficient)
N W �U.kZ 10/18/21
Signature of-ertified Well Contractor Date
6.Is(are)the well(s): 01'ermanent or ❑Temporary By signing this form,I hereby certify that,the wel/(s)was(it-ere)constructed in accordance
with 15A NC4C 02C.0100 or 15A NCAC 02C.0100 Well Construction Slandards and that a
7.is this a repair to an existing well: ❑Yes or EUNo 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 ir21 remarks.section or on the back of this frm. 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.
h'or multiple injection or non-water supply wells ONLY with the same construction,you can
submit one firm SUBMiTTAL iNSTUCPiONS
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple wells list all depths ifdijjerem(example-3@200'and 2 tt f00') construction to the following:
10.Static water level below top of casing: 36 (fit,) 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 Welts 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) 5 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