GW1-2023-02693_Well Construction - GW1_20230411

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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 14.WATER ZONES
Y FROM TO DESCREMON
Well Contractor Name 155 ft. 162 fL 6 gpm
2465-A 220 fL 228 fL 4 gpm
NC Well Contractor Certification Number Y5.OUTER CASING for multi-cased wills OR LINER if a licable
FROM TO DIAMETER THIC[flVESS MATERIAL
Derry's Well Drilling, Inc. APR 1 12023 0 ft- 145 ft- 6 1/8 '- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
362700 = °` "n7i FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#. fe ft. in
List all applicable well permits(i.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 TIHCKNF.SS MATERIAL
f6 ft. in.
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lndustriaVCommercial ❑Residential Water Supply(shared) 18,GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 R- 20 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 1'a licable
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 DESCRD TION color,hardness,soi0rack type size.etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Brown Dirt
4.Date Wed(s)Completed: 2/1 0/23 well iD# 15 ff• 245 ff. Blue Rock
ft. ft.
5a.Well Location: ft. ft.
Clive Levy & & Seams:53',59',78',85',95', 110', 115',
Facility/Owner Name Facility ID#(if applicable)
ft 125', 150', 155'=6gpm, 195',210',
18168 Mary Ln., Locust 28097 f
220-228=4gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 7310
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreesAwnutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latlhong is sufficient)
N W rl "" ' 3/7/23
Signa of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this farm,I hereby certify that the wells)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?]No 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#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
8.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 INSTUCTIONS
9.Total well depth below land surface: 245 (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:
10.Static water level below top of casing: 32 (ft) Division of Water Resources,Information Processing Unit,
Ifrvater 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 well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) t i
Division or Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 106 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 department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Re ources Revised August 2013
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