GW1--07575_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Dwight L. Huneycutt FFRMATERZONES TO DESCRIPTION
Well Contractor Name 107 ft 110 ft 1 gplil (321'-325'=4gpm)
4070-A 350 ft• 355 ft I ; 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap likable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 44 ft 6 1/8 ;in. SDR-21 PVC
Company Name • 16.INNER CASING OR TUBING(geothermal closed-loop)
375638 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft ; in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft ' in.
3:Well Use(check well use):
17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) RJResidential Water Supply(single) ft ft. in
❑IndustriallCommercial ❑Residential Water Supply(shared) A GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 It. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 tt, Bentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) . -
❑Aquifer Storage and Recovery ❑Salinity Sarriet`-,. FROM TO MATERIALEMPLACEMENT METHOD
ft. ft.
OAquifer Test ❑Stormwater Drainage
ft. f.
❑Experimental Technology ID Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain site,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 27 ft , Brown Dirt/Rock
4.Date Well(s)Completed: 10/5/23 Well ID# 27 ft 365 ft Slate
ft. ft.
5a.Well Location: ft. ft.
Daniel Gusev • ft ft Seams:54',72', 107'=1g, 113', 154',210',
Facility/Owner Name Facility IDS(if applicable) ft. ft. 68,290,307,312,321=4g,
Buster Rd, Stanfield 28163 ft. ft. 350'=5g
Physical Address,City,and Zip 21:REMARKS - r" —
Stanly 141488 ,[6:.:w,.,,i , V. _., i
County Parcel Identification No.(PIN) i 1 n
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification i NOVV �`'��
(if well field,one laUlong is sufficient) : // '
N W L. 1/ n �} ;, ' ";17313.i
717
/r 'is
Signature •Certified Well Contractor Date
6.Is(are)the well(s): fr7Permaneut or ❑Temporary By signing this form,I 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 P)No 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 l'
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
submit one form. SUBMITTAL INSTUCTIONS '
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9.Total well depth below land surface: 365 (ft) 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: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
4 ,
11.Borehole diameter: 6 (in.) 24b.For Iniection 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:
(ie.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
10 Air 24c.For Water Supply&InjectionkWells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Granular construction 1/2 lb. well to the county healtli department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013