GW1-2023-02687_Well Construction - GW1_20230411

i
WELL CONSTRUCTION.RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES I^
!�*790
DESCRIPTION
Well Contractor Name t F a o a`r L,^ 1' ft. 5 gpm
2465-A APR Z ZQ23 285 fr. 1 gpm
NC Well Contractor Certification Number s 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THIC1QiESS MATERIAL
Derry's Well Drilling, Inc. ,r,=, ,;;,.,,,. ,, ,,;,:::-11 1 :� 0 ft 50 ft 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loon)
368519 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tr. ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DUMETER SLOT SIZE Tin MATERIAL
❑Agricultural ❑Municipal/Public ft. It. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft fL in.
❑IndustrialtCommercial ❑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 fL 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 ft ft.
IA TO MATERL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DFSCRmnON color,hardness soil/rock type rain she,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 15 ft Brown Dirt
4.Date Well(s)Completed: 6/25/22 Well ID# 15 ft. 340 ft. Blue Rock
ft ft.
5a.Well Location: ft. ft
Michael Burris
ft rr- Seams:,60',65'-76'=3gpm,92', 111', 116',
Facility/Owner Name Facility ID#(ifapplicable)
t. ft ft. 250'121', 130', 1965'==9pm, 180'=19pm,
27776 Hatley Farm Rd, Albemarle ft.
250,285—1 gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 33039
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 / w• 7/20/22
Signa of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
ivith ISA NCAC 02C.0100 or ISA NCAC 02C.0200[Yell 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 ivell oivner.
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 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: 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 INSTUCTIONS
9.Total well depth below land surface: 340 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
F'or multiple wells list all depths rfdiTerent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
lfrvater 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
13a.Yield(gpm) 6 Method of test: AI r 24c.For Water Supply&Infection 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
I