GW1--02008_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD
For Interiral Use ONLY:
This form can be used for single or multiple wells fll
1.Well Contractor Information: -
Dwight L. Huneycutt 14.WATER ZONES i
9 y FROM TO DESCRIPTION
Well Contractor Name 297 ft 305 , R I 1 gpm
4070-A ft. ft. I
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NC Well Contractor Certification Number 15.'OUTER CASING(for multi-cased wells)OR LINER Walt Iicable)
FROM TO' DIAMETER' ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 48 ft 6 1/8 SDR-21 PVC -
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
290741 FROM TO DIAMETER!' ' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. i in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,eta) •
ft. ft. iin.'
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) , ft ft. M.
.Qlndustrial/Commercial , ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL f EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 q, ft , .
Non-Water Supply Well: 3 Bent.Chips Gravity
❑Monitoring ❑Recovery 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 MATERIAL EMPLACEMENT METHOD
H. ft j ' ,
❑Aquifer Test ❑Stormwater Drainage ft it. i
❑Experimental Technology ❑Subsidence Control •
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer ' FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other.(explain under#21 Remarks) 0 ft 9 ft '' Brown Dirt
10/30/23 9 ft 18 ft Boulders
• 4.Date Well(s).Completed: Well ID# 18 ft 25 ft Brown Rock
5a.Well Location: 25 ft 525 ft* i Slate
Robert Layton ft ft Seams:90', 192',254',397-305'=1gpm
Facility/Owner Name Facility IMO(if applicable) ft. ft
37338 Melton Rd., Albemarle 28001
ft ft. : . i. ?
Physical Address City,and Zip - t r t 4—kl
• 21.REMARKS ' ,
Stanly 35983 ' 1-1''1+' 0 1 2024
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: �, i1'.'• Ctr v'DG
(if well field,one 1at/long is sufficient)
N w Z,GiALVtt-,1-. „ 11/15/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1SA 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'vie!!owner.
. If this is a repair,fill out known well construction information and explain are nature of the
repair under 821 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
&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 one form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 525 (ft) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths it—different(example-3@200'and 2@100) construction to the following:
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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 Centei?,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) • 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
• 12.Well construction method: construction to the following:
.(ie.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 .
1 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 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