GW1-2023-01654_Well Construction - GW1_20230213

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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 " r ) 14.WATER ZONES f
?i FROM TO DESCREMONI
Well Contractor Name �'- dy' 198 fr. 200 ft. I I 15 gpm
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2465-A ��N 1 rc ft �
NC Well Contractor Certification Number ry,,_- v 2023 15.OUTER CASING for multi-cased wells OR LINER if a livable
l
'rl• ,;,ry lj�Y(a FROM TO DIAMETERI THICKNESS MATERIAL
Derry's Well Drilling, ate �a t 0 ft. 70 61/8 SDR-21 PVC
rry 9 t7� -3 Un,'
Company Name 16.INNER CASING OR TUBING I!eothennal closed-loop)
139274 FROM TO DIAMETER' ' THICKNESS MATERIAL
2.Well Construction Permit#: & ft. in.
List all applicable well permits 0.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/Coolin'g Supply) ®Residential Water Supply(single) iL ft '°
❑Industriai/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft. Bentonite Pumped
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable,
FROM TO MATERIAL I 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,soilfrock sire,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 26 ft. Soft Red Dirt
n ft.
4.Date Well 5/24/22 s)Completed: Well ID# 26 32 Gravel
32 ft 60 ft. .Broken Slate&White Flint
5a.Well Location:
60 ft 205 ft. ;, slate
Rodney Holshouser
s
Facility/Owner Name Facility ID#(if applicable)
44504 Ledbetter Rd., New London ft. ft- Seams,:83',138',150',180', 198'=15gpm
rL It.
Physical Address,City,and Zip 21.REMARKS
Stanly 3719
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) ', /l
x W, 9A& W. 6/19122
Si aurre of Certified Well Contrncto Date ,
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certify that'the rveU(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or PJNo copy of this record has been provided to the well owner.
If this is a repair,fill out known ivell construction information and explain the nature of the
repair under 921 remarks section or on the back ofthis 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 u jection or norrwater supply ivells ONLY with the same construction,you can 'r
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (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:
29 Division of Water Resources,Information Processing Unit,
10.Static water level below tap of casing: (ft) G
lfwater level is above casing,use"+" 1617 Matz Service Ce'ter,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cei ter,Raleigh,NC 276994636
15 Air 24c.For Water Supply&Infection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this ford 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