GW1-2023-02686_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 267 ft- 275 n 8 gpm
4070-A ;'"Y.. ft
ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if
ap enble)
A PR 1 1 2023 mom I TO I DIAM " 1 -MAL ETER I THICKN MAW
Derry's Well Drilling, Inc. 0 ft. 148 fr 161/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUDING(geothermal closed-IDUP)
TO DIAMETER THI MATERIAL
2.Well Construction Permit#: 381124 C FROM ft ft. in.
List all applicable well permits(I.e.County,State,Trariance,Injection,etc.) ft. & in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE -I-THICKNESS I MATERIAL
ElAgricultural OMunicipal/Public ft fL hL
FROM
fL
ElGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. It,
in
oIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrioa ion 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well: FROM
3f L 20 fL Bentonite Pumped
OMonitoring ORecovery ft.
Injection Well: ft. ft.
CAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ElAquifer Storage and Recovery OSalinity Barrier ft. ft.
DAquifer Test E]Stormwater Drainage ft. %
oExperimental Technology 13Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
DGeothennal(Closed Loop) OTracer FROM TO DESCRIMON(color,hardness,soil/rock type,grain size,etc.)
DGeothennal(HeatingJSooling Return) 00ther(explain under#21 Remarks) 0 ft. 9 ft Red Dirt
4,Date Well(s)Completed: 10/22/22 Well IDN 9 IL 17 fL Brown Dirt
17 "L 300 It- Slate
5a.Well Location- ft. ft.
Gentry Parnell ft ft
Facility/Owner Name Facility DV(if applicable) ft ft Seams:53% 140', 192',218',255',
28521 Hatley Farm Rd, Albemarle 28001 ft. ft 267'=8gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 12730
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Wong is sufficient)
Poe4416tl�n 11/15/22
Signature of0firtified Well Contractor Date
6.Is(are)the well(s): 101ermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stwidards and that a
7.Is this a repair to an existing well: OYes or EINo 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 of this form. 23.Site diagram or additional well details:
You may use the back of this page to 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 ivells ONLY with the same construction,you can
submit one form SUBMIT TALINSTUMONS
9.Totalwell depth below land surface: 300 (ft) 24a. For All Wells: Submit this f6 ma within 30 days of completion of well
For multiple iveRs list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 40 00 Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (iR-) 24b.Em Infection Wells ONLY. In addition to sending the form to the address in
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 Center,.,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: Air 24e 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 Resomm Revised August 2013