GW1--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