GW1--02001_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 • I
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES • " l
Y FROM TO DESCRIPTION
Well Contractor Name 156 it. 162 ft. I ! 5 gpm
2465-A ft. ft. 1 ; .
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- 45 ft 6 1/8 1 1D- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
396664 FROM TO DIAMETER ' THICKNESS• MATERIAL -
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count',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 ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. 'n
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 • Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 f4 20 ft Bentonite Pumped
Injection Well: ft. ft. I'
❑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 LlSubsidence 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 it 25 f6 Red Dirt&Rock
8/21/23 25 It 280 itI Blue Rock
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: R ft,
Shelley Lowe ft. ft. 109', P
Seams:65,74',87', 115, 125',
Facility/Owner Name Facility ID#(if applicable)
Old Parker Rd., Albemarle 28001 ft. ft. 135', 156'=5gpm,215',236',246',
ft ft.Physical Address City,and Zip i i 1 1 Y•'+
21.REMARKS. t,k.L. r:0,.a:,,.
r r''' :
Stanly 7431
County Parcel Identification No.(PIN) • A P R t) 1 2024
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: jn;�„j; ; ;]r- ,��, ,
(if well field,one lat/long is sufficient) / ,,,, ll i Cii�rr`Ct,,3�� ng
URIA
N W !�f/. �GCYL4.r./ "8130/23
S. ture of Certified Well Contracto ' • Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify 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 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#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 fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 280 (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 Iniection 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
13a.Yield(gpm) 5 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