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HomeMy WebLinkAboutGW1--07589_Well Construction - GW1_20231121 I WELL CONSTRUCTION RECORD For Internal Use ONLY: ' This form can be used for single or multiple wells 1.Well Contractor Information: Dwight L. Huneycutt 14.4. MATERZTONES DESCRIPTION Well Contractor Name 72 ft. 75 ft- I 3 gpm 4070-A 167 ft. 175 ft. I ' 3 gpm 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- 61/8 in* SDR-21 PVC Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 356302 FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: ft. ft. in. List all applicable well permits(i.e.County,State,Variance,Injection,eta) ft. ft. i in. 3.Well Use(check well use): 17.SCREEN •Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Ag`icultural ❑Municipal/Public ft ft. in ❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) it. rt. in. ❑lndustriallCommercial ❑Residential Water Supply(shared) IS.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑Irrigation 0 R. 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 OSalinity Barrier ft. ft i ❑Aquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology OSubsidence 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. 11 ft. 1' Red Dirt 5/18/23 11 ft- 19 ft I i Brown Dirt 4.Date Well(s)Completed: Well IO# 19 ft. 23 ft. I ; Brown Rock 5a.Well Location: 23 ft' 300 ft. Slate James Phillipy ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:72'=3gpm,89',98',129', Sam Rd,Albemarle 28001 • ft. L ft. 167'=3gpm Physical Address,City,and Zip : 21.REMARKS - Stanly 24364 • . • " �::r ii v y :!yt; . County Parcel IdentificationNo.(PIN) NOV "?, I 2023 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (if well field,one lat/long is sufficient) I I r; , "n F").•. 3,-1-; s,1 t,i:��L -,?, . 06/12/23 N W Signature of Certified Well Contractor j Date 6.Is(are)the well(s): ❑Permanent or OTemporary By signing this form,I hereby cerltfy that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or INo copy of this record has been provided to thellwell 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 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 1 ' 9.Total well depth below land surface: 300 (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: 36 (ft,) Division of Water Resources,information Processing Unit, If water level is above casing,use.. " 1617 Mail Service Center,Raleigh,NC 27699-1617 i , 11.Borehole diameter: 6 (in.) - 24b.For infection Wells ONLY: In addition to sending the form to the address in Rota 24a above, also submit a copy of this form within 30 days of completion of well 12.Well construction method: ry construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, •FOR WATER SUPPLY WEI IS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 6 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