GW1-2023-02690_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:
Dwight L. Huneycutt FROM ZTO ONE- . DESCREMON
Well Contractor Name 150 ff 160 ff , 40 gpm
ft. ft.
4070^A C +.z •1. ' e;. -:
.:� r .,.. LI..
NC Well Contractor Certification Number 15.OUTER,CASING for multi cased wells OR LINER if a"licab►e
APR y 7 2O2 ry FROM TO DIAMETER TffiC ESS MATERIAL
Derry's Well Drilling, Inc. f I� 1 1 3 0 ft' 46 ft- 161/8 "L SDR-21 PVC
Company Name t l t;" , I p t_• 16.INNER CASING OR TUBING. eothermaI closed-loop)
378067 t l FROM TO DIAMETER THICICa S MATERIAL
2.Well Construction Permit#:
�' ft. ft
List all applicable well permits(i.e.Coun(K State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Public fL❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft m
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) 18.GROUTFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft- Bentonite Pumped
❑Mottitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19•SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnen,soiUmck type size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 9 ft. Brown Dirt
Slate
4,Date Well(s)Completed: 1 O/12/22 well ID# 9 f• 165 IL
ft. ft.
5a.Well Location: ft. f
Steve Burleson e. ft.
Facility/Owner Name Facility ID#(if applicable)
25002 Bost Rd., Albemarle 28001 iz fr Seams:70',99', 107', 132', 150'=40gpm
ff, ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 3160
County Parcel IdcmifiFation No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)N w ,L. r V r(/
11/1/22
Signature ofCertified 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
with 15A NCAC 02C.0160 or 15A NCAC b2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No 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 of this farm. 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 25 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above easing,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
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.anger,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) 40 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfeetiontype• 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
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