GW1--02005_Well Construction - GW1_20240401

i
WELL CONSTRUCTION RECORD
For Internal Use ONLY: I •
This form can be used for single or multiple wells I
1.Well Contractor Information: . '
John W. Huneycutt 14.WATER ZONES 1
FROM TO DESCRIPTION!
Well Contractor Name 355 ft 360 ft I ! 6 gpm.
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETERI I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 47 ft. 6 1/8 linj, SDR-21 PVC
Company Name (� 16.INNER CASING OR TUBING(geothermal closed-loop)
390796 FROM TO DIAMETER. ` THICKNESS MATERIAL
2.Well Construction Permit#: • ft. ft. !in:`
List all applicable well penults(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): r-17.SCREEN - -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ,
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT `
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft
Non-Water Supply Well: 3 Bent.Chips Gravity
QMonitoring ORecovery 3 ft. 20 ft Bentonite ' Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DL1TEit1AL. EMPLACEMENT METHOD
ff. It ,
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
QExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,son/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 ft Brown Rock
4.Date Well(s)Completed: 8/2/23 Well ID# 15 f4 380 itSlate
ft. ft. I.
5a.Well Location: ft. ft. '
Kirk L. Honeycutt ff. ft ,
Facility/Owner Name FacilityIDu(if Seams:65,70,87, 113, 119, 130, 152
applicable)
20852 Indian Mound Rd, Albemarle 28001 ft ft 15',188',250',272',292',355'=6g
ft ft.
Physical Address,City,and Zip 21.REMARKS 4' ` 't n n 0 f
;L' ayr a"J .Y
Stably 6261 ,
County Parcel Identification No.(PIN) I APR J I e024
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1 -
(if well field,one lat/long is sufficient) <"rr.✓";1 '"•.'`•"3'7'f''.g Uit t
N W # 1 + j 3 Jc:� 8/30/23
Si a of Certified Well Contractor 1 : Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certt&that the well(s)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: OYes 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 ofthis 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 i
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 380 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100' construction to the following: j
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 Inflection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this1 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.) t
Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,FOR WATER SUPPLY WELLS ONLY: I NC 27699-1636
13a.Yield(gpm) 6 Method of test: Air 24c.For Water Supply&Infection 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