GW1--05039_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 181 ft' 190 ft• 5 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap icable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 81 ft. 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
399772 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural • ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) f• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) l8.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.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology OSubsidence 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) DOther(explain under#21 Remarks) 0 ft. 6 ft. Brown Dirt
4.Date Well(s)Completed: 5/8/24 Well iD# 6 ft' 22 ft. Wet Brown Dirt
22 ft. 66 ft. Junky Brown Rock
5a.Well Location:
Phil Trufant 66 ft. 300 ft* Slate
ft. ft. Seams:89',93', 105', 116', 132',
Facility/Owner Name Facility iD#(if applicable) ft. f.t
20702C Huneycutt Mill Rd., Albemarle 28001 ft. a _44 175', 181'=5g
Physical Address,City,and Zip 21.REMARKS )1 "-••,--
Stanly 140001 '-' k.. ' i `-.
County Parcel identification No.(PIN) fi 1 L1G J. 0 t1�f,24
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: jr,';,;.', - 3--
(if well field,one ladlong is sufficient) '..'c.,, ;
N W
i il lit t L. C. j.• ' • 5/14/24
Signature of edified 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.0i00 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND 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: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@/00') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
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
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:
(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 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-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013