GW1-2023-02701_Well Construction - GW1_20230411

i
i
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES t 1
g Y FROM TO DESCRIPTION 1 I
Well Contractor Name 95 ft 99 ft. i 2 gpm
4070-A fL &
r" 15.OUTER CASING for multi-eased wells)'OR LINER if a Gcable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 150 fr 6 1/8 1 SDR 21 I PVC
Company Name APR 1luzi16.RIMER CASING OR TUBING(geothermal closed-loop)
379114 FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt ft.
List all applicable ivell permits f.e.Counry.Stare, fionce,)njectiq>i.etc ._ .,
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft' 3 ft- Bent.Chips' Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 fG Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK(ifa livable) i
❑A uifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E1%IPLACE1%ENT METHOD
q ry ft. ft
❑Aquifer Test ❑StormwaterDrrainage ft. f.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necess )
❑Geothermal(Closed Loop) ❑Tracer FROM I To DESCRIPTION(color,hardness•sonfrock gain sac,e(c.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 15 ft Red Clay
9/13/22 15 ft. 27 ft Brown Dirt
4.Date Well(s)Completed: Well 1D#
27 ft. 35 ft. Brown Rock
5a.Well Location: 35 ft 400 f`- Slate
Paula Blalock n n
Seams:59',67',75',95-99'=2gpm,
Facihty/Owner Name Facility ID#(ifapplicable)
It. i<• 112, 156'
Plank Rd, Norwood 28128 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 33202
Comity Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lar/long is sufficient) ,
N W 7nCt/ 10/2/22
Signature o£Certified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the u•ell(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: ❑Yes or 0No 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 due
repair under 921 remarks-section or an Ike back ofthis forms. 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.
Por multiple injection or rum-water supply ivelb OM,Ywith the sane construction,you can
submit one form. SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
(br multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 40 (ft,) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary... 24a above, also subunit 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 m 2 Method of test: Air 24a For Water Supply&Injection Wells:
(gp ) 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013