GW1--02722_Well Construction - GW1_20240507

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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 14.WATERZONES
Y FROM TO DESCRIPTION
Well Contractor Name 75 ft 78 ft I I 45 gpm
4070-A 98 ft 102 ft. I I 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER„ : THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 46 ft- 61/8 ;i"- SDR-21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
405362 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 I SLOT SIZE THICKNESS MATERIAL
•
DAgricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
0 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. t
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
• FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier • ft. ft. i
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I.
❑Experimental Technology ❑Subsidence 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 ft 6 ft. i Red Dirt
3/5/24 6 ft 19 ft Brown Dirt/Rock
4.Date Well(s)Completed: Well ID#
19 ft 145 ft Slate
5a.Well Location: ft ft.
Tong Va Xiong ft. ft
Facility/Owner Name Facility ID#(if applicable) Seams:52,66,69',72,,75-78-45g,
ft. ft 98-102'=5gpm
St. Martin Rd.,Albemarle 28001
ft. ft.
Physical Address,City,and Zip , r^.. T' C`-- .Fr•`
zl.REMARKS G,r';.?~c. t r t`•ts 3_r a .
Stanly 142375
County . Parcel Identification No.(PIN) I' M AY V ! LO1 L t+
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:G .L ii1037:1C:,4:.�i. :�:,-c-s�.r,-U• i)r"
/D F Qi3i29/24
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary • By signing this form,i hereby certify 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: ❑Yes or 0No 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: 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 b
9.Total well depth below land surface: 145 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdifferent(example-3 f200'and 2(43100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in ,
Rota 24a above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: ry construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) l '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 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