GW1--04995_Well Construction - GW1_20230807

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name c-' r:r; f ..,,,, 99 ft- 103 ft* 2 gpm (150'-155'=6gpm)
4070-A L'` Li 173 ft 180 ft- 67 gpm
NC Well Contractor Certification Number A U G 0 7 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. inc,- `.,,,,, ,,r- o ft• 48 ft- 61/8 in- SDR-21 Pvc
COmpany Name r, ""�''9-' Ufl 16.INNER CASING OR TUBING(geothermal closed-loop)
9 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 369027 ft. ft. , in.
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 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft rt. in.
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑IndustriallCommercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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) '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rt. ft.
❑Aquifer Test ❑Stormwater Drainage •
It. ft.
❑Experimental Technology ❑Subsidence Control '
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ID Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 8 rt. Red Clay
4/17/23 8 ft. 17 ft. Brown Dirt
4.Date Well(s)Completed: Well ID# 17 ft 23 ft Brown Rock
5a.Well Location:
ZacharyChandler 23 ft- 185 fL Slate
Facility/Owner Name FacilityID#(ifapplicable) ft. ft- Seams:55',68',72',81',95',99'=2gpm,
ft. ft. 150'=6gpm, 169', 173'=67gpm
Union Grove Church Rd, Albemarle 28001
f4 ft.
Physical Address,City,and Zip
21.REMARKS
Stanly 19973
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
tt-
N W � .C_. 5/5/23
Signature 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
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 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 1121 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
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 tire same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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@l00) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 75 Method of test: Air
24c.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 1 department of the county where
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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