GW1--05011_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 I
Well Contractor Name -�, . r..� 165 ft, 170 ft. I i 6 gpm
4070-A L..i t 235 ft• 240 ft• I ! 4 gpm
NC Well Contractor Certification Number 4 G 7 2023 I 15.OUTER CASING(for multi-cased-wells),OR LINER(if ap licable)'
v FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 69 ft. 61/8 SDR-21 PVC
Ifl:v,.•tn,OJ}�;'1'�f+.L'4`R'lrae, 16.INNER CASING•OR TUBING.(geothermal closed-loop) -
Company Name !f O
371611 Crr°`08134., 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 DMunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.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.
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['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD _
DAquifer 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.)
0 Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) 0 ft. 8 ft. Red Dirt
4.Date Well(s)Completed: 2/6/23 Well IV/ 8 fr• 26 ft Brown Dirt
26 ft 37 ft• Brown Rock
5a.Well Location: 37 ft- 280 ft- Slate
Woodrow Rinehardt ft ft
Facility/Owner Name Facility ID#(if applicable)
Old Concord Rd, Albemarle 28001 ft ft Seams: 150', 165'=6gpin, 195',
ft ft. 235'=4gpm
Physical Address,City,and Zip Z1..REMARKS -
Stanly 35793
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 lam(/. 3/15/23
Si of Certified Well Contractor Date ,
6.Is(are)the well(s): ©Permanent 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 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 421 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: 280 (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@100') construction to the following:
10.Static water level below top of casing: 36 (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 Iniection 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
10 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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