GW1-2023-02697_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I
Dwight L Huneycutt 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name 158 ft- 160 ft. 1 gpm
4070-A 370 1- 1390 ft- 3 gpm
NC Well Contractor Certification Number A rt 1 2023 15.OUTER CASING formulti-cased wells) P
FROM I DIAMETER P=--mila M14RIAL I
Derry's Well Drilling, Inc. ft- 145 ft. 1 61/8 SDR-21 PVC
0
r
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER.. THICKNESS MATERIAL2.Well Construction Permit N: 114596 in,
well
List all applicable permits(i.e.County,State,State,Variance.Injection,etc.) ft I
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS f MATERIAL
ftft, in.
ClAgricultural ON[unicipal/Public
Meothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. it.
in
ClIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01nigation 0 & 3rr. Bent.Chips Gravity
Non-Water Supply Well: 3 It- 20 ft- Bentonite Pumped
OMonitoring EIRecovery
Injection Well: ft. ft.
ElAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicablpl
FROM TO MATERIAL I EMPLACEMENT METHOD
ElAquifer Storage and Recovery OSalinity Barrier ft. ft.
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) oTracer FROM TO DESCRIPTION(color,hardness,soillrock tw,grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 11 ft. Brown Dirt Rock
4.Date Well(s)Completed: 11/3/22 Well ID# 11 " 400 It. Slate
ft. ft
5a.Well Location: ft. fL
Dallas Hathcock ft. % Seams:TY,87',110', 133% 158'=1 gpm,
Facility/Owner Nam Facility 1D#(if applicable) ft 170', 188',370'-390'=3gpm
8698 Coftonville Rd, Norwood 28128 fL &
Physical Address,City,and Zip 21.RENIARKS
Stanly 140818
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latflong is sufficient)
W 11115/22
Signature of tertifled Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary 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: OYes or EINo 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 tire 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
S.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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftiferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level Is above casing,use 1617 Mail Service Center,Raleigh,NC 21699-1617
I I.Borehole diameter: 6 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: I
(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,RaWgb,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 ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013