GW1--07593_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
1.Well Contractor Information: '
Dwight L. Huneycutt 14.WATER ZONES-- - - .•,I (' -- -- -- -
9 Y FROM TO DESCRIPTION
Well Contractor Name 69 ft. 75 ft. I 6 gpm
4070-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) -• --' -
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 50 ft. 61/8 ! i°• SDR-21 PVC .
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)` ` u-- ,
117354 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) glResidential Water Supply(single) fG ft hi.
❑IndustriallCommercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring DRecovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,19.SAND/GRAVEL PACK(if applicable) - -- - ... •- , -` -- •
FROM TO MATERIAL ' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage .
ft. ft.
❑Experimental Technology 0 Subsidence Control "
.20.DRILLING LOG(attach additional sheets if necessary) --- - •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 6 ft Red Dirt
4.Date Well(s)Completed: 6/27/23 Well II?# 6 ft- 24 ft Brown Dirt
24 ft 41 ft Brown Rock '
Sa.Well Location: 41 ft 245 ft Slate
Melissa Zito
Facility/Owner Name FacilitylD#(ifapplicable) ft. ft Seams:55-58',69-75'=6g,88',94', 121',
R. ft 134',152', 1,65',198',211'
St. Johns Dr., Stanfield 28163ft. 1, : ., ,
Physical Address,City,and Zip 4 v
Zl.REMARKS '....- .o,..
F.
Stanly 31310 it NOV 2 1 2023
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/m.inutes/seconds or decimal degrees: """' i %" ' 1�r•i
22.Certification: .,.
(if well field,one lat/long is sufficient) °is_S L7
N q, �G�e% � 7/15/23
Signature of Certified Well Contractor • Date
6.Is(are)the well(s): ©Permanent or OTemporary
By signing this form,I hereby cert that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fr]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 .
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
is
9.Total well depth below land surface: 245 (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:
10.Static water level below top of casing: 30 (ft.) Division of Water Reso i rces,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 2413,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,etc.)
Division of Water Resources,Underground Injection Control Program,
FORWATER SUPPLY WELLS ONLY: 1636 Mail Service Center,l Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: Air
24e.For Water Supply&InlectionnWells:
Also submit one copy of this forth within 30 days of completion of
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county healtli department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013