GW1-2023-01655_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 11
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION] I
Well Contractor Name R � 195 ft. 200 ft 20 gpm
4070-A m a '`�i ,r' fL ft. I ,
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we1Ld OR LINER if applicable)
FROM TO DIAMETER I 'THICKNESS MATERIAL
Derry's Well Drilling, Inc. FEB ZQ23 o fL 46 ft. 6 118 SDR-21 PVC
Company Name ljnix 16.INNER CASING OR TUBING(geothermal closed-loo
364758 �,9 eSQi O FROM TO DIAMETER ' THICKNESS riLl, RIAL
2.Well Construction Permit#: ft. ft. in:
List all applicable well permils(i.e.County Slate,Variance,h jectioA 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
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) it ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) M GROUT
FROM I TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft Bentonite ' Pumped
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a lirable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer r28 "-
TO DESCRIPTION color,hardness,saivrocl e, rain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft Red Clay
4.Date Well(s)Completed: 5/24/22 Well lD# 19 ft Brown Dirt
28 ft. Brown Rock
5a:Well Location: 35 ft Junky Brown Rock
John Giddens
35 f- 245 fk i Slate
Facility/Owner Name Facility ID#(if applicable)
ft. f Seams:,52:,59', 117', 150', 178', 187',
24459 Canton Rd., Albemarle 28001
ft. ft. 190', 195'=20gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 137839
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W 6/10/22
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify brat the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iVell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis 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 ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 245. (fL) 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:
20 Division of Water Resources,Information Processing Unit,
10.Static water level below top of rasing: (ft) i
Ifwater level is above casing,use"+ 1617 Mail Service Centel,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of thisform within 30 days of completion of well
12.Well construction method: Rotary 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.Yield(gpm) 20 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013