GW1--04997_Well Construction - GW1_20230807

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1 I
1.Well Contractor Information:
Derry L. Huneycutt X r. �?*�s�7 j rr— 14.WATER ZONES
RI—
,� A .7 try D FROM TO DESCRIPTION i
Well Contractor Name I \ C. '.'w �y d
130 fr• 135 fr• 2,gpm (165-167'=1gpm)
2663-A AUG 0 1 2023 180 ft 185 ft 2 gpm (250-254'=55gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
r lrnorrt-45;icn Pr`-';"'4s ' Ur'' FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. Dwoiso(� o fr• 50 ft- 61/8 in-, SDR-21 l PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) .
383307 FROM TO DIAMETER • THICKNESS MATERIAL
2.Well Construction Permit#: 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 ft. in.
❑Geothermal(Heating/Cooling Supply) ]Residential Water Supply(single) fl ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation • 0 rt. 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)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary) - '
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 12 ft. Red Dirt
4.Date Well(s)Completed:'2/8/23 Well ID# 12 ft 28 ft Brown Rock
28 ft 255 ft Blue Rock
5a.Well Location: ft. ft.
Michael Eudy ft ft.
Facility/Owner Name Facility 11)11(if applicable)
Austin Rd., Albemarle 28001 ft ft Seams: 130'=2gpm, 165'=1gpm, 180',2gpm
ft. rt. 250'=55gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 10509
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)
N W V�'�"' 3/1/23
Signature of ertified Well Contractor i, Date
6.Is(are)the well(s): 1ZZPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ]No 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
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: 255 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 19 ,, (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail 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
Rotary
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 27699-1636
60 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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