GW1--05133_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:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 197 ft. 225 ft. 3 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a • bk)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 50 it 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
357356 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. is -
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER _SLOT SIZE THICKNESS - MATERIAL --7
tt ft• in.
❑Agricultural ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. R�
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft20 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. R
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 25 ft. Brown Dirt&Rock
1/12/24 25 ft• 345 ft. Slate
4.Date Well(s)Completed: Well ID#
ft. R.
5a.Well Location: fL rt.
Michael Tate ft.
Seams:59',70', 110', 130', 165',
Facility/Owner Name Facility ID*(if applicable)
ft ft. 197-225'=3g
Mary Ln, Locust 28097 ft. ft
t .. _
Physical Address,City,and Zip 21.REMARKS '-^ -• r � + ,
Stanly 1006
County Parcel Identification No.(PiN) J(I V I G J 0 I�euj24
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: „
(if well field,one Iat/long is sufficient) ` �� // ••' 1 - '"" -" . ; _;.
�L ! / ire`.::.,:..
N W
2/gb%24
Si re of Certified Well Contractor Date
6.Is(are)the well(s): GaPern anent or ❑Temporary By signing this form,1 hereby certifr that the well(s)was(were)constructed in accordance
with/SA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or EINo 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
9.Total well depth below land surface: 345 (f.) 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@100') construction to the following:
10.Static water level below top of casing: 30 (g,) Division of Water Resources,Information Processing Unit,
If water 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
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 3 Method of test: Air 24c.For Water Supply&Injection Wells:
(gp ) 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