GW1--07579_Well Construction - GW1_20231121

! '
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 1 i
Y FROM TO DESCRIPTION
Well Contractor Name 242 ft 246 ft I 4 gpm
2465-A ft ft. i
NC Well Contractor Certification Number `15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER - THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft 6 1/8 Ent SDR-21 PVC
Company Name p Q 16.INNER CASING OR TUBING(geothermal closed-loop)
382845 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
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. t in
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 It Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 ft- Bentonite • Pumped
❑Monitoring ❑Recovery
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) OTracer FROM TO DESCRIPTION(color,bantam,soil/rock type,grain size,ate.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 11 ft Red Dirt
8/19/23 11 f< 22 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
22 - ft. 345 ft. Slate
5a.Well Location: ft, ft ,
Thomas Von Canon ft. ft.
Facility/Owner Name Facility ID#(if applicable) -
Pennington Rd, Albemarle 28001 (Lot 2) ft ft. Seams:56', 116', 15s',242'=4gpm
f. ft.
Physical Address,City,and Zip 21.REMARKS - - - ._
Stanly 382845 , . , „.,.,I �''y f E-1-
• County Parcel Identification No.(PIN) ?
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: NOV L��J
22.Certification:
(if well field,one lat/long is sufficient) '',, JJ
N W `dt' W. 7/ 4 "i -`...^91• 15/23'' '�it i
Signs of Certified Well Contractor Date
6.Is(are)the well(s): I27Permanent or ❑Temporary By signing this form,I hereby certibi that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RINo 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 ofthis 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 i
9.Total well depth below land surface: 345 (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(100) construction to the following:
10.Static water level below top of casing: 30 (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
Rota 24a above, also submit a copy of tliis1 form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,mtaty,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) 4 Method of test: Air 24e 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
1 '
1