GW1--04999_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1
John W. Huneycutt 14.WATER ZONES
Y FROM TO . DESCRIPTION.
Well Contractor Name r'-^^ 7,--- ,.� �...r.a �-. 180 ft. 185 ft' I ' 3 gpm
2465-A i'l,C L..i ki Li 230 ft 237 ft 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
AUG 7 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 79 ft• 6.1/8 in- SDR-21 PVC
Company Name lnfo y4l.^1 +'r'' w''`°�t`y"` 16.INNER CASING OR TUBING(geothermal closed-loop)
373870 Di�° T" FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.) R ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIOIESS MATERIAL
H.
❑Agricultural OMunicipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriallCommercial ❑Residential 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 f. 20 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 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,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 ft Red Dirt
1/3/23 ' 20 ft 70 ft• Brown Dirt&Rock
4.Date Well(s)Completed: Well ID#
70 ft 245 ft Slate
5a.Well Location: ft ft.
Kevin Walter ft ft Seams:85',90', 130', 140', 168', 180'=3gpm
Facility/Owner Name Facility ID#(if applicable)
ft. ft 230'=5gpm
Austin Rd., Albemarle 28001
ft. ft.
Physical Address,City,and Zip 21.'REM1fA1tKS
Stanly 24107
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 geZP a2. 7/7catri&-' 1/31/23
Signat of Certified Well Contractor Date
6.Is(are)the well(s): 127Permanent or ❑Temporary By signing this form,I hereby cert fy 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 ElNo 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 1i21 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: 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: 245 (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@100) construction to the following:
Division of Water Resources,Information Processing Unit, '
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"+" 1617 Mail Service CenteD•,Raleigh,NC 27699-1617
II.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:
(ie.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
13a.Yield(gpm) 8 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 department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013