GW1--07582_Well Construction - GW1_20231121

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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 1
FROM TO DESCRIPTION
Well Contractor Name 167 ft- 170 fr. I 45 gpm
4070-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-. 56 ft 6 1/8. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
391414 FROM TO DIAMETER THICKNESS MATERIAL •
2.Well Construction Permit#: ft ft. t 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
IL IL in.
❑Agricultural ❑Municipal/Pubiic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) R8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft., 3 f- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitorihg ❑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,bantam,,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. 7 ft Red Dirt
• 4.Date Well(s)Completed: 6/6/23 Well ID# 7 ft 24 ft Brown Dirt
24 ft 42 ft - Brown Rock
5a.Well Location: 42 ft- 185 ft Slate
Stanly Construction ft. ft.
Facility/Owner Name Facility ID#(if applicable) •
28160 Austin Rd, Albemarle 28001 ft. it Seams:9T, 101',105',116',
ft ft. 167-170'�45gpm
Physical Address,City,and Zip 21.REMARKS .- - .T
Stanly 142112 : . •�.�- e-.
L. r; 9 � i
County Parcel Identification No.(PIN) NOV
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i x ���J
22.Certification:
(if well field,one lat/Iong is sufficient) ;
N W Z7 c i` � 1=t>6/2$%23:.i.ry, ice: "i
Signature of erti$ed Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)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 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 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: 185 • (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdii erent(example-3@200'and 2@I00) construction to the following: a
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10.Static water level below top of casing: 28 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Ce!ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) • 24b.For Infection 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
12.Well construction method: Rotary 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
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13a.Yield(gpm) 45 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. '
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water !Resources Revised August 2013