GW1--01995_Well Construction - GW1_20240401

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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 FRO144.WMATER ZONES DESCRIPTION
Well Contractor Name 59 ft 65 ft I 4 gpm
4070-A 238 ft 240 ft I , 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 44 ft• 61/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
401452 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
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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.
❑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 OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
0 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. i Brown Dirt .
11/25/23 11 ft 300 ft Slate
4.Date Well(s)Completed: Well ID# ft it.
5a.Well Location: ft ft.
Jack Morton
ft. Seams:51',59'=4gpm,112', 151',
Facility/Owner Name Facility MN(if applicable)
ft ft. ' 162',238'=2gpm
40313 Hoops Ct.,Albemarle 28001
ft ft .
Physical Address,City,and Zip 2.
21.REMARKS- L= - �"'"„_.�a
Stanly 410 ;'""c ,s ' '
County Parcel Identification No.(PIN) APR R e) 1 Z U 14
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: x fir
(if well field,one lat/long is sufficient) i1twr r,re4 i1 t`•-^. 5(bi,.:-g Vn)i
D •
N W 7417aitreit-CANC(i 5/23
Signature o citified Well Contractor Date
6.Is(are)the well(s): ®Permanent or OTemporary By signing this form,I hereby certdi that the wells)was(were)constructed in accordance
with ISA 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 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#2)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 i
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 ifdrfferent(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
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
6 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 Ib• 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 Resotirces Revised August 2013