GW1--05144_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 158 ft 162 ft 2 gpm
2465-A 260 ft. 265 ft 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a usable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 62 ft- 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
334647 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft, hi.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL —
❑Agricultural ❑Municipal/Public ft. to `
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. to
❑IndustriaUCommercial ❑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: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stomtwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rack type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 30 ft. Brown Dirt
3/30/24 30 ft- 300 ft. Slate
4.Date Well(s)Completed: Well ID# ft. . ft.
5a.Well Location: ft. ft.
Jerry Swaringen ft. ft Seams:77',87',92', 110', 130', 158'=2g,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 185', 195',215',250',260'=2g
20455 US Hwy 52, Albemarle 28001 ft. ft. -
Physical Address,City,and Zip 21.REMARKS `'
Stanly 37974
County Parcel Identification No.(PIN) i d .i (tf t
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: !'
(if well field,one lat/long is sufficient) d5e 22.Certification: / ,,(�
�a 6t • Y r �-1. 4/25/24
N W
Si a of Certified Well Contractor Date
6.Is(are)the well(s): 121Pennanent or ❑Temporary By signing this form,1 hereby certify 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 ONO 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 contraction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ff.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths idifferent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of easing 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 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
4 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