GW1-2023-01663_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:
14.WATER ZONES I. i
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name - ^a e' ;� 414 ft 420 ft 3 gpm
4070-A FEB 2023 ft ft.,
NC Well Contractor Certification Number V ]5.OUTER CASING for multi-cased wells OR LINER if a tiiable
In?Ci,ti. 'ice FROM TO DIAMETER THICR7VESS RATERIAL
Derry's Well Drilling, Inc, ., .. � � `� Un;i o ft. 48 ft 6 vs sDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo -
380775 FROM TO DIAMETER THICKNESS 5UTERIAL
2.Well Construction Permit#: ft ft
List all applicable ivell permits(1 a Coun(g State,Variance,Injection,etc.)
ft, ft im
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATER1&L
❑Agricultural ❑MunicipaVPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fc in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
❑hri ation 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL •EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage ft n
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness saiuruck type,grain she,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft Red Dirt
4.Date Weil(s)Completed: 0/18I22 ID# $ ft-
Well 16 ft Brown Dirt
16 r' 29 ft j; Brown Rock
5a.Well Location: 29 ft 445 ft Slate
Jarrid Pack fL ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft Seams:52',58',67',75',90', 108', 116',
26019 Morlin Rd., Albemarle 28001
ft ft 139',218',230',296',315'414'=3gpm,422'
Physical Address,City,and Zip 21.REMARKS
Stanly 15367
County' Parcel Identification No.
5b.Latitude and Longitude in degrees/minutes/seconds or,decimal degrees: 22•Certification:
(ifwell field,one latilong is sufficient)
N `,Ir T�GZ�,L_. Gu�t.P.cd 10/31/22
Signature KfCertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)ivas(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 the well owner.
If this is a repair,fill out known ivell construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page tti'provide additional well site details or well
S.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 INSTUCI'IONS
9.Total well depth below land surface: 445 (ft) 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:
10.Static water level below top of casing: 59 (it) 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 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
• f
13a.Yield(gpm) Method of test: Air
24a 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