GW1-2023-02702_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:
Dwight L. Huneycutt 14.WATER ZONES t
FROM TO DESCWTION I
Well Contractor Name 307 ft 310 I 1 1 gpm
4070-A I:;>>a .� _ ;,' : ff.- fL ft i
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a livable)
APR 12023 FROM TO DIAM1fETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 66 ft 61/8 SDR 21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM To DIA7IIETER
38098t'
i_,.'.^:�•�•., THICKNESS MATERIAL
2.Well Construction Permit#: L' ft. ft in.
List all applicable well permits(i.e.County.State,Variance,Injecting etc.)
ft ff. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public & & in.
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 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 ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft.
MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessn ) -
❑Geothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnem soillrock type,grain s metc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 14 ft. Brown Dirt
4.Date Well(s)Completed: 9110/22 Well ID# 14 ft. 36 ft Brown Rock
36 ft- 465 ft Slate
5a.Well Location: ft ft
Claude Bowers tt ft- Seams:72',75',79', 105', 113', 137', 175',
Facility/Owner Name Facility 1B#(if applicable)
ti rr• 189',210',236',295',307'=1gpm
8267 River View Rd, Norwood 28128 ft. ft
Physical Address,City,and Zip - 21.REMARKS
Stanly 19666
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N w 10/2/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the irell owner.
If t1Ns is a repair,fill out known well construction Information and explain the nature ofthe
repair under a21 remarks section or on the back ofthis 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 ivelty OM.Y with the same construction,you can
submit one form. SUBMITTAL INSTUCTTONS
9.Total well depth below land surface: 465 (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 45 (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
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.Yield(gpm) 1 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.
I
Form OW-1 North Carolina Department o£Eavironment and Natural Resources—Division of Water Resources Revised August 2013