GW1-2022-04266_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Der L. Huneycutt 14.WATERZONES
Y FROM TO DESCRIPTION
Well Contractor Name 118 125 ft 8 gpm
2663-A 165 f° 175 ft' 7 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wtpS OR LINER if a kcal le
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 49 ft- 6118 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
354183 FROM TO DIAMETER THICKNESS MATERIAL
Z•Well Construction Permit#: ft. fr. In.
List all applicable well permits(i.e.County,State,Variance,injection,eic.)
f4 ft. in, _
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
APR
❑Agricultural ❑Municipal/Public ft. ft. in. l'0 S -
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT Ij"•:r.: „
FROM TO MATERIAL EMPIA - T,M ETHOD=B-AMOUNT. �''�
❑IRA atlon ft. ft- ,
Non-Water Supply Well: 0 3 Bent.Chips GravityV
❑Monitoring ❑Recovery 3 fL 35 ft- BentonitePumped
lnjedion Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tZ ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack tyM grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. g ft. Brown Dirt&Rock
4.Date Well(s)Completed: 8/4/21 Well IN 9 ft- 15 ft. Brown Rock
15 fL 185 ft- Slate
5a.Well Location: R. ft.
Colten 8r Sarah Bun-is ft. ft.
Facility/OwncrName Facility IDll(ifapplicable) ft. ft
Silver Springs Rd, Norwood 28128 ft. fL Seams: 100'=3g, 118'=5g, 165'=7g
Physical Address,City,and Zip 21.REMARKS
Stanly 18311
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W PQiLtJ(-z— � 8/26/21
Signature ot'Ce 'fed Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 hereby certify thin the well(v)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 rfthis record has been provided to the well owner.
If this is a repair,fill out known ivell conevuction information and explain the nature of the
repair under:21 remarks section or on the back ofilus 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.
Por 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: 185 (ft.) 24a. For All Wells: Submit this form ,vithin 30 days of completion of well
her multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,Information Processing Unit,
Ifxater level is abore caving,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 Rotary 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.field(gpm) 15 Method ofttst: 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.
I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013