GW1--01998_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells.
1.Well Contractor Information: .
Dwi ht L. Hune cuff 14.WATER ZONES s t
g Y FROM TO DESCRIPTION
Well Contractor Name 113 ft- 121 ft- I ' 2 gpm
4070-A 192 ft- 200 ft- I i 5 gpm
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. 0 ft• 51 ft- 61/8 1 iA SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
334346 FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ) in.
List all applicable well permits(t.e.County,State,Variance,Injection,etc.) ft ft. pin
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultu al ❑MunicipallPublic ft,, in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. in
•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: ft. 20 i< Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft. ,
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL, EMPLACEMENT METHOD
ft. ft,
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❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
1 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Red Dirt
4.Date Well(s)Completed: 8/15/23 Well # 9 ft 23 ft Brown Dirt
ID
23 ft- 42 ft- i. Brown Rock
5a.Weil Location: 42 ft- 300 ft• Slate
. Katy L. Huneycutt
Facility/Owner Name y Facility ID//(if applicable) ft. Seams:65',72',89', 113-121'=2g,
ft. ft. ' ' 133-136', 192'=5g
Old Mill Rd., Locust 28097 ft. ft.
Physical Address,City,and Zip 21.REMARKS Vi,;___ .,..'y.—.t V Z...,Lod
Stanly 138830 p
County Parcel• �Identification No.(PIN) 'lc •APR t) 12024
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1 a -av
(ifwell field,one lot/long is sufficient)
infoi m.riz•+;i •�' 4/.'l l�x
N W
D�� s"'eft ' 8/30/23
Signature of ertified Well Contractor t, Date •
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that die well(s)was(were)constructed in accordance
with iSA NCAC 02C.0100 or I5A 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 s ell'owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of thisfOrm. 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: 300 (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:
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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 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: 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
13a.Yield(gpm) 7 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