GW1-2023-02672_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for shoe or multiple wells
1.Well Contractor Information: I
Dwi 14.WATER ZONES
ght L. Huneycutt FROM TO DESCREMON
Well Contractor Name 197 ft' 205 ft. j 1 6 gpm
4070-A 312 ft- 318 IL 4 gpm
IS.OUTER CASING for multi-cased wells) 1111VIT
NC Well Contractor Certification Number APR 1 2023 FROM To DIAMETER M—LIMUff 2 MATERIAL
Derry's Well Drilling, Inc. ft 1 61/8 '- 1 SDR-21 PVC
Company Name r 1 16.INNER CASING OR TUBING(ecothermal closed-loop)
192296 FROM - TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit N: ft. --ft in
List all applicable ivellpernzils rL a County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal/Public R. ft
in
ElGeothernial(Heating/Cooling Supply) VIResidential Water Supply(single) &
rt is
01ndustrial/Commerciall OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
-
DIrrigation 0 ft' 3 ft- Bent Chips Gravity
Non-Water Supply Well:
DMonitoring ORecovery 3 fl- 20 ft- Bentonite Pumped
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(ifariplicable)
0Aquifer Storage and Recovery OSalinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStonnwater Drainage ft. ft
OExpefimental Technology []Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OCTeotheffnal(Closed Loop) 07fracer FROM TO DESCRIPTION(color,hardness,soiUmck type,gr2in size.etc.)
ElCreothermal(HeatinglCooling Return) 00ther(explain under#21 Remarks) 0 ft- 6 ft. Red Dirt
4.Date Well(s)Completed, 3/30/23 Well EN 6 rt 18 ft Brown Rock
18 rL 345 ft- Slate
So.Well Location: fL ft.
Amy Fuller ft. ift.
Facility/Owner Name Facility ID#(if7applicable) ft. ft. Seams:56',70'94',113', 135!=2gpm,
Rowland Rd., Locust 28097 % ft. 197'=4gpm,312'=4gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 29996
County Parcel Identification No.(PIN) r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one lat(long is sufficient)
N W 4/5/23
Signature of Certified Well Contractor V Date
6.1s(arc)the weH(s): fOPermanent or OTemporary By signing this form,I hereby certify that Cite irell(s)was(Were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or K)Ncs copy of this record has been provided to the well owner.
If this is a repair,fill out knmvn well construction inforination and explain the nature of1he
repair under#21 remarks section at,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 ofwells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same contraction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivell;list all depths i(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 A) Division or 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: I
(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) 10 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 de partment of the county where
constructed.
FormGW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013