GW1-2023-02709_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.Dwight L. Huneycutt FROMATER TONES DESCRIPTION
Well Contractor Name 152 ft 158 ft' 1 2 gpm
4070-A 240 ft- 245 ft. 2 gpm
Is.OUTER CASING for multi cased wells OR LINER if a livable
NC Well Contractor Certification Number ,; ..a ;_ FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 61 ft 6 1/8 'a SDR-21 PVC
Company Name s L J 16.INNER CASING OR TUBING f2eothermal closed-loop)
381929 FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit# - ! ` it ft in-
List all applicable well permits(.e.County,Sldte,''Ydridnce,.(njection,elc) f4 ft im
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE HI TCKNESS MATERIAL
fL ft in.
❑Agricultural ❑Municipal/Public
(H gt g Supply) Supply g ) fr. it, in
. +
❑Geothermal eatin Coolin Su 1 ®Residential Water Su 1 (single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
ROM TO MATERIAL EMPI,ACEINEN'1'METHOD&AMOUNT
❑lrri ation 0 ra 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt 20 ft. Bentonite Pumped
Injection Well: ft. ft❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENTtrIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. R.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG fattach additional sheets if recess
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION tutor,hardness soilhnrk e n sire eta
❑Geothermal(HeatinglCooling Return) ❑Other explain under#21 Remarks) 0 ft. 21 ft. Brown Dirt
10/25/22 21 It- 29 f` Brown Rock
4.Date Well(s)Completed: Well ID# 29 rt. 48 ft. Junky Blue Rock
Sa.Well Location: 48 ft 265 f` Slate
Billy Blalock ft H. Seams:69',77',89',104', 117', 126',
Facility/Owner Name Facility ID#(ifapplicable) & t+• 152-158'=2gpm, 166'-174`, 190',207',214',
32727 Valley Dr., Albemarle 28001 % & 223',235',240'=2gpm,252'
Physical Address,City,and Zip 21.REAiARKS
Stanly 3134
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
�(ifwell field,one tat/long is sufficient) !/
N W 11/15/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this fornx I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1SA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZINo 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 tl21 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 wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 50 (R•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
6 (in.) 24b.For Injection 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:
(Le.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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 4 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.
Form GW-1 North Carolina Department of Enviroutnent and Natural Resources—Division of Water Resources Revised August 2013