GW1-2023-02678_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
i
1.Well Contractor Information:
14.WATER ZONES
John W. Huneycutt FROM TO I DESCRIPTION
Well Contractor Name 95 ft- 100 ft. I 2gpm
2465-A '' t. .,'�` '�.` ..;'� 195 ft 200 ft. i 6gpm
NC Well Contractor Certification Number (� 15.OUTER CASING for multi-cased wells OR LINER if a licable
APR 1 ZOZ3 FROM TO DIAMETER TRICIINESS MATERIAL
Derry's Well Drilling, Inc. 0 tt 46 ft. 6 1/8 ;n SDR-21 PVC
Company Name c, z I n 16.INNER CASING OR TQBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL.
37968 f.,
2.Well Ctinstraction Permit#: tt ft in
List all applicable well permits(i.e.County,State,Variance,Injectio);etc.)
ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE Tinclo ESS MATERIAL
ft ft in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 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 licable
❑Aquifer Storage and Recovery []Salinity
Salinity Barrier ft. TO ft. MATERLAI. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 25 ft. Brown Dirt
8/17122 25 fL 225 ft- Blue Rock
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft ft.
Seth Floyd ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) It. It. Seams:56',85%95'=29pm, 10', 172',
36727 Cooper Rd., Norwood 28128 ft ft 178', 190', 195'=69pm
Physical Address,City,and Zip 21.REMARKS
Stanly 5813
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 W9� 9/15/22
SignVaeofCertiliedWcH Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that lire wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the ivell 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 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
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 some construction,you can
submit oneform. SUBM`17AL INSTUCTIONS
9.Total well depth below land surface: 225 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (R•) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter* 6 (in.) 24b.For Infection 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 well
12,Well construction method Rotary construction to the following:
(Le,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(,-pm) 8 Method of test: Air 24a 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