GW1-2023-01657_Well Construction - GW1_20230213

I '
l �
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14•WATER ZONES
l f
9 Y FROM TO DESCRIPTION
Well Contractor Name � ;�� �'�) 472 IL 475 ft. I I 3 gpm
4070-A
I ft. ft.
15.OUTER CASING for multi-cased wells OR LINER if a livable
NC Well Contractor Certification Number + FROM TO DIAMETER I THICKNESS MATERIAL
2�23 e. fr. �,m:
Derry's Well Drilling, Inc. ��, alp__ o 77 6 1/8 SDR-21 PVC
—� tj+,+�a F,�Li , 16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name '� v�+L i9 t'?.•n GrS FROM TO DIAMETER THICKNESS DtATERtAL
2.Well Construction Permit#: 329807 ft. ft i in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft. HL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f4 fL in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rn
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
IDIrri ation 0 ft' 3 It- Bent.Chips Gravity
Non-Water Supply Well:
3 {r 20 {r Benfonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if a livable "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. ;
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if ssarlo
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type in sire,erc
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 0 ft- 15 & Red Dirt
4.Date Well(s)Completed: 7/13/22 Well ID# 15 fL 37 ft. Brown Dirt
37 fL 69 ft. Brown Rock
5a.Well Location: 69 fL 500 f" ' Slate
Michael Crump ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ,� rr. Seams: 107',250',308',472'=3gpm
32207 Pennington Rd, Albemarle 28001 ft. ft
Physical Address,City,and Zip 21.REN ARKS
Stanly 32383
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 IPM4 /_ Y 7/29/22
Signature oirCertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary BY signing this farm,I hereby certify chat the rvell(s)iras(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 0No copy ofthis record has been provided to rite ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the '
repair under#21 remorks section or on the back of this form. 23.Site diagram or additional well'details:
You may use the back of this page io provide additional well site details or Weil
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply mvells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
i
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenr(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: 46 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I '
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 this 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.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel r,Raleigh,NC 27699-1636
Z4c.For Water Supply&IDiection�Wlls:
e
13a.Yield(gpm) 3 Method of test: Air ,.
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 2013
I'