GW1--02003_Well Construction - GW1_20240401

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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:
John W. Huneycutt 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 90 ft: 110 ft• I ' 12 gpm
2465-A 230 ft• 235 ft• I 18 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lieable)
FROM TO DIAMETER : THICIINESS MATERIAL
Derry's Well Drilling, Inc. o ft• 50 ft• 61/8 I'a SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) '
394557 FROMDIAMETER TO THICKNESS MATERIAL
2.Well Construction Permit ii: ft. ft. ;in.
List all applicable well permits(i.e.County,State,Variance,Injection,eta)
ft. ft. 'in.
3.Well Use(check well use): ' 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft fc in
ft❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. °1
❑Industrial/Comercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO
m MATERIAL'. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 it 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)
FROM TO MATERIAL • EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier
ft. ft.
❑Aquifer Test OStormwater Drainage ft. rt.
❑Experimental Technology OSubsidence Control • '
c.. 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 10 ft. Red Dirt
9/11/23 10 ft• 25 ft• Brown Dirt , _
4.Date Well(s)Completed: Well ID# 25 ft• 35 ft• Brown Rock
5a.Well Location:
Eric Kelly 35 240 ft. .ft•
r. Slate 1
Seams:74,82,90-110'=12g, 122',
Facility/Owner Name Facility lDii(if applicable) ft. ft. ! 130',135',230'=18g
Smith Rd., Stanfield 28163 ft. ft. i.~.`_ - >,, 'q, ,1,
Physical Address,City,and Zip 4 .;«r ':d y
21.REMARKS l,: ,
Stanly 1898 ' Q F,P 4 t 202-4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ttl4'''':''it iP`.C.,5crn,,,IQ Ursa '
22.Certification:
(if well field,one lat/long is sufficient) �� / D`I G:fitOG
N W Z W. r f 9/30/23
Sign of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certity that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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 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: 240 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 2@100') construction to the following:
I'
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
Rotary24a 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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