GW1-2023-02677_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:
14.
DWigttL, FR
t L. Huneycutt WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 102 f`- 115 ft. 20gpm
4070-A _ -- - ft. ft.
NC Well Contractor Certification Number _ '1 " I5.OUTER CASING for multi cased wells OR LINER if a licahle
I.r..., .i=e..u=
FROM TO DIAMETER THICKNESS MATERIAL.
Derry's Well Drilling, Inc. 1 1 �Q23 0 ft- 47 ft- 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
y 355074 7 ��.-•sF )1'li_ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ` ` ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injegtlon;e)e j 4
ft, ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 rt. Bentonite Pumped
❑Monitoring ❑Recovery
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. ft.
❑Aquifer Test ❑Stornwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,solvrock typr rain Sim etc)
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 12 ft. . Red Clay
5/28/22 12 ft- 20 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
20 `• 27 ft. Brown Rock
So.Well Location: 27• ft 200 ft. Slate
Rigoberto Giron fL ft.
Facility/Owner Name Facility 09(if applicable)
Old Davis Rd., Norwood 28128 ft. f Seams:55',76', 102-115'=20gpm
ft. ft.
Physical Address,City,and Zip 21.RFAIARKS
Stanly 140184
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one hit/long is sufficient)
N W 6/15/22
Signature of Ccdffled Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
ivith 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy ofthis 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 921 remarks section or on the back of this farm. 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCITONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths U dierent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 24L For Iniection Well 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(gpm) 20 Method of test: Air 24c.For Water Supply&Infection 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 blazer Resa I Revised August 2013