GW1--05004_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:
John W. Huneycutt •14.WATER ZONES Y FROM TO DESCRIPTION
Well Contractor Name �, ,v i re)
ft 70 ft- 1 J gpm (315'-320'=1 gpm)
} i
2465-A E L.e L..I V r L I 350 ft. 373 ft. 3 9Pm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lieable)
A U G 0 r r 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 45 ft 61/8 in. SDR-21 PVC
Company Name Inro;ril .Vc.n Pr;:��b&,..gl.irt>7 16.INNER CASING OR TUBING(geothermal closed-loop)
365292 D4/41..r3AY.3 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
ft. ft in.
:Agricultural ❑Municipal/Public
❑Geotheal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
rm
❑Industrial/Commercial ❑Residential Water Supply(shared) I&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 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 15 ft Brown Dirt
4.Date Well(s)Completed: 3/30/22 Well KW
ft 405 ft Slate
ft. ft.
5a.Well Location: ft. ft
Scott&Kristy Galusha ft. ft Seams:68-70'=1gpm,75',85',90',98', 125'
Facility/Owner Name Facility 1Db(if applicable)
24298 Mini Airport Rd., Albemarle 28001 f` 135', 170', 196',205',210',234',265',269',
274',315=1gpm,331',350-373=3gpm
Physical Address,City,and Zip 21.REMARKS .
Stanly 33729
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 W9.ell'L4/28/23
Si lure of Certified Well Contractor Date
6.Is(are)the well(s): l2lPermanent or OTemporary 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 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#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
&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: 405 (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@I00' construction to the following:
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10.Static water level below top of casing: 38 (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 Injection 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:
(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
13a.Yield(gpm) 5 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013