GW1-2023-02676_Well Construction - GW1_20230411

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'S
Well Contractor Name _ 65 ft' 75 ft' 5gpm
2465-A .J'i e; T' 110 ft 115 & 75 gpm
NC Well Contractor Certification Number j� 15.OUTER CASING' for multi cased wells OR LINER if a livable
APR 1 ZQZ3 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. - 0 ft 47 ft- 61/8 SDR-21 I PVC
Company Name •r„;;; _ :i',' t'i 16.INNER CASING OR TUBING( eothermal closed-luoul
38351'7 J FROM TO DIAMETER THICK IA THICKNESS MATERL
2.Well Construction Permit#• f �-'tti- ft ft is
List all applicable well permits fl.a County,State,Variance,h jectiot;etc.) rt h• is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER I SLOT SIZE I THICKNESS MATERIAL.
❑Agricultural ❑Municipalt'Public ft ft.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 1 Bent.Chips Gravity
Non-Water supply well:
❑Monitoring ❑Recovery 3 "1 20 ft- Bentonite Pumped
Injection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
ft, ft.
❑Aquifer Test ❑Stomiwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional streets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DFSCRIMON color,hardness soiVrock Mw,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other explain under#21 Remarks) 0 rt• 25 fL. Brown Dirt
1119/23 25 ft- 120 ft- Blue Rock
4.Date Well(s)Completed: Well i1D# ft. fL
Sa.Well Location: ft. ft.
Jason Keeney fr. ft,
Facility/Owner Name Facility ID#(ifapplicablo)
1994 Plank Rd, Norwood 28128 ft ft Seams:65'75'=5gpm, 110'-115'=75gpm
ft e.
Physical Address,City,and Zip 21.REMARKS
Stanly 6600
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field,one lat/long is sufficient) a)N W 9�� ��� 2/1123
Signa of Certified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form;I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l?3No 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 120 (ft.) 24a. For All Wells: Submit this fenn within 30 days of completion of well
For multiple wells list all depils ifdioerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 10 UP 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
Rota 24a above,also submit a copy of this form within 30 days of completion of weil
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test:
$0 Nr 24e.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