GW1--07576_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: '
Dwight L. Huneycutt 14.WATER ZONES. 1 ;
:7 Y FROM TO DESCRIPTION
Well Contractor Name 366 ft 370 ft I 1 gpm
4070-A ft. ft I ; "
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if p licable) ,
FROM TO DIAMETER t. . THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft 6 1/8 I 'm SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) "
391395 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft hi.
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. m
❑Geothermal(Heating/Cooling Supply) E Residential Water Supply(single) ft. ft. in. •
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1s.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. ft !'
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tra4er FROM TO DESCRIPTION(color,hardness,soil/rock type,gram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 22 ft. Brown Dirt Rock
4.Date Well(s)Completed: 10/3/23 Well ID# 22 ft 600 ft Slate'
ft. ft.
5a.Well Location: ft ft
Daniel Gusev ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft Seams:89', 177',238',366'=1 gpm,
Buster Rd, Stanfield 281-Co3 ft. ft 414'
Physical Address,City,and Zip y.
21.REMARKS
Stanly -- 20232 , - -r,-k.. ,i y> y.. ,
County Parcel Identification No.(PIN) f NOV 2 I 21'23
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, e lat/long is sufficient) 22.Certification:
MC _._.'-,i , — . :Y
N W D 7' , ` '�10/31/23
Signature o Well Contractor Date
6.Is(are)the well(s): i27Permanent or ❑Temporary
By signing this forme,I hereby certifr 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 ElNo 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 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 ' j
submit one form. SUBMITTAL INSTUCTIONS
j.
9.Total well depth below land surface: 600 (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:
i •
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: *addition to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(ie.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: Alr 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.
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Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water RI sources Revised August 2013