GW1-2023-01661_Well Construction - GW1_20230213

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 i
' n '' �'^�"`'a FROM TO DESCRIPTION
Well Contractor Name o 'py .. ,190 ft' 200 f6 ' f 4 gpm
4070-A FEB ft. %
tB 2023 15.OUTER CASING for multi cased wells OR LINER if a licahle
NC Well Contractor Certification Number ;nil, ;�� ;e,v�
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. �;;_�� = �711, . o 45 ft 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothennal closed-loop)
360243 FROM TO DIAMETER TRICIUMS MATERIAL
2.Well Construction Permit#: ft. ft. I in.
List all applicable well permits#.e.County,State,Variance,Injection,etc) ft it. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, In.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. M 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:
❑Monitoring ❑Recovery 3 fL 20 IL Bentonite Pumped
Injection Well:, ft ft j;
❑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 ❑Stormwater Drainage
R ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 0 ft- 8 ft Brown Dirt
4.Date Well(s)Completed: 12/1/22 well ID# 8 ft- 16 ft. Brown Rock
16 tt 300 ft Slate
5a.Well Location: ft, ft.
Melaine Dibenedetto ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Boone Caudle Rd., Norwood 28128 ft. f` Seams:50',57',70',89', 115', 156',
ft & 177', 190'=4gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 33179
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: !'
22.Certification;
(ifwell field,one IaUlong is sufficient)
N W h 12/15/22
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A 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 die well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 1:
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 F
submit one form. SUBMITTAL INSTUCITONS
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 all depths j different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 47 (ft.) Division of water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Cef ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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:
(Le.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei t i r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
4 Air 24c.For Water Supply&Injection 4Wells:
, ,.
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount- 112 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