GW1--05155_Well Construction - GW1_20240830

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
FROM TO DESCRIPTION
Well Contractor Name 278 ft- 285 ft' 1/2 gpm
4070-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a limbic)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 44 ft. 61/8 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
363794 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(.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 DMunicipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation 0 e• 3 ft Bent.Chips Gravity
Non-Water Supply Well: —
❑Monitoring ❑Recovery 3 ft• 20 ft Bentonite_ Pumped —
Injection Well: R 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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain sine,_etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks) 0 ft. 14 it. Brown Dirt
4.Date Well(s)Completed: 4/30/24 Well ID# 14 ft 750 ft- Slate
ft. ft.
5a.Well Location: ft. ft.
Matthew Eudy ft. ft.
Seams:51',70', 112', 133', 149', 171', 197',
Facility/Owner Name Facility ID#(if applicable)
3619 EudyRd., New London R. 210',231',27s'=1/2g
ft ft.
Physical Address,City,and Zip 21.REMARKS -
Stanly 7454 6 . ^• . •• .
County Parcel Identification No.(PIN) AUGA
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: U" J d eG24
22.Certification:
(dwell field,one lat/long is sufficient)if
, .,,..
N W C^G t Lei ',..5/ /2
Signature o ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 INSTU C TIONS_
9.Total well depth below land surface: 750 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:
Division of Water Resources Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Infection 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:
(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 m 1/2/2 Method of test Air 24c.For Water Supply&Injection Wells:
(gpm) Also submit one copy of this form within 30 days of completion of
136.Disinfection type Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013