GW1-2023-01642_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Huneycutt 14•WATERZONES-
John W. Rune @ 1
Y FROM TO DESCRIPTION I
Well Contractor Name .-- — 118 fr• 125 ft 15 gpm
�' :� ' >7 fir.
2465-A I;' ft ft
NC Well Contractor Certification Number _ 15:OUTER CASING for multi-cased wells OR LINER if a licable
FEB 1 v 2023 FROM TO DIAMETER! THICKNESS MATERIAL
'Derry's Well Drilling, Inc. l� J 0 ft• 52 ft• 61/8 SDR-21 I PVC
Company Name lni%�11�i$i:�l ?f{{^.;.y�..�yr 1.'Iia 16.INNER CASING ORTUBING(geothermal closed-loo ,
360595 ✓t�e'�v FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(,e.County,State,variance,Injectiog etc.)
ft. ft in.
3.WeII'Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS nIATFRUL
❑Agricultural ❑MunicipaUPublic ft ft in
1
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft tt in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL I� 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 applicable)
FROM TO MATERIAL is EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Bariier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft fr.
❑Experimental Technology ❑Subsidence Control Ij '
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION valor,hardness,soiurock type sim,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain underW21 Remarks) 0 ft 12 & i Red Dirt
7/25/22 12 ft- 38 fr j Brown Dirt&Rock
4.Date Well(s)Completed: WeU IDtf
38 ft 145 fL j Slate
5a.Well Location: ft. ft h
Jordan Johnston ft &
Facility/Owner Name Facility ID#(if applicable)
ft ft Seams:73',88', 115', 118'=15gpm
Garrett Way, Albemarle 2800.1 ft ft - r
Physical Address,City,and zip
21.REMARKS
Stanly 35706
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) i
N W 8/10/22
Signs 'Certified Well Contractor Date
6.Is(are)thewell(s): ©Permanent or ❑Temporary
B1'signing(his farm,I hereby cer[tfy,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 ❑No 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 ofthis 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 ONLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS i
9.Total well depth below land surface: 145 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all.depths ifdifferen[(example-3@200'and 2@100) construction to the following: I
10.Static water level below top of casing: 20 (f1) 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
Rotary 24a above, also submit a copy of this fornl within 30 days of completion of well
12.Well constriction method: construction to the following:
(ie.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
13a.Yield(gpm) 15 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form withm 30 days of,completion of
13b.Disinfection type: Granular Amount: 1/2 lb• well construction to the county health department of the countywhere
constmcted.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resource I s Revised August 2013
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