GW1--02013_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: ! '
John W. Hune cutt • 14.WATER ZONES i
Y FROM TO DESCRIPTION I
Well Contractor Name 56 ft. 58 ft. 3;gpm (99-102'=3gpm)
2465-A 11 o ft 120 ft. 1 • 1 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. 0 ft. 47 ft. 61/8 i"• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop). •
399740 FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: ft ft. in.
List all applicable well permits(Le.Count',State Variance,Injectiot;etc)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: most To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. m
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. 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:
OMonitoring ❑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 OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
tt. ft
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO - DESCRIPTION(color,hardness,son/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 20 ft ! Brown Dirt
4.Date Well(s)Completed: 11/14/23 Well IN/ 20 ft 180 ft' Granite
ft. ft
5a.Well Location: ft. ft -
Jeff Coley it ft.
Facility/Owner Name Facility ID#(if applicable) Seams:,56-58-3g,67r,75,90,99.-_
3g,
ft ft 1 Q-a. �='�s:.�
City -.�
35887 Lake Dr., Albemarle 28001
` ft ft. =...ti.71 V J
Physical Address,City,and Zip
21.REMARKS
Stanly 18741 ;APK d i L024
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I, DWathOG
(if well field,one lat/long is sufficient) /
N W• l 2 . Y I 11/30/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certf#that the'well(s)was(were)constructed in accordance
with ISA 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 END 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 form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 180 (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths tfdlerent(example-3@200'and 2@I00) construction to the following,
I
10.Static water level below top of casing:
30 (ft) Division of Water Resources,Information Proee'cing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 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