GW1--07588_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
J Y FROM TO DESCRIPTION
Well Contractor Name 98 ft 99 ft. I 1 6 gpm
4070-A 101 ft• 109 ft- I I 9 gpm
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 94 ft. 61/8 ' lit SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
377552 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.
0 Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. it. in.
❑lndustrial/Comercial ❑Residential Water Supply(shared) 18.GROUT
m
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. 1
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
G. it [
❑Aquifer Test ❑Stormwater Drainage
ft. ft. i
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 42 f. • Brown Dirt
Junky Brown Rock
4.Date Well(s)Completed: 5/23/23 Well ID# 42 ft- 78 ft.
78 ft. 185 fr. ; Slate
5a.Well Location: ft. ft.
Jamie Wilkins ft. ft.
Facility/Owner Name Facility 1011(if applicable) •
ft. ft. Seams:98'=6gpm,101-109'=9gpm
Ridenhour Rd, Richfield 28137 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 139971 of ., �'
County Parcel Identification No.(PIN) I q n qq
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: N O V 1 2023
(if well field,one lat/long is sufficient)
N W ryzio7catt€''1/ < ..,�,6/1.2/2a.�
Signature of ' lied Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary
By signing this form,I hereby cerr6 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: [Wes or E INo copy of this record has been provided to thewell owner.
If this is a repair,fill out known well construction information and explain the nature ofthe I '
repair under 421 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
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells:• Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following: I'
1; .
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
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: hi 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: rY 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
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13a.Yield(gpm) 15 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013