GW1--05000_Well Construction - GW1_20230807

WELL CONSI RUCTION RECORD For Internal Use ONLY: {
This form can be used for single or multiple wells
1 1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES i '?
Y FROM TO DESCRIPTION
Well Contractor Name t „� 148 ft 155 fh 2 gpm
2465-A , • - N.C Le L.e "D 190 ft 195 ft % 3 gpm
NC Well Contractor Certification Number AUG15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)-
I IG 7 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 o ft 60 , ft. 61/8 im SDR-21 PVC
Company Name to c fra-,L) h Pr:-.Y ;,;;,t' UnItt 16.INNER CASING OR TUBING(geothermal closed-loop)•
372152 v iia hf 7 FROM TO DIAMETER THICKNESS. , MATERIAL
2.Well Construction Permit#: ft. 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 THICKNESS MATERIAL
J ❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 1t R'
1S.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared)
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.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. it.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft 40 ft Brown Dirt
1/6/23 ' • 40 ft 245 ft Blue Rock
4.Date Well(s)Completed: Well ID# , ft. ft.
5a.Well Location: ft. . ft.
Chase &Zoe Frick
ft. ft. Seams:65',70',87',95',.128',
Facility/Owner Name Facility ID#(if applicable)
Loop Rd., Norwood 28128 • ft. ft. 2148-155'=2gpm, 190-195'=3gpm,214',
28
Physical Address,City,and Zip 21.REMARKS
Stanly 2019 .
County Parcel Identification No.(PIN}
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one 1at/long is sufficient)
N W 1/31/23
Signs of Certified Well Contractor • Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 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 ONo 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
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(([different(example-3@200'and 2@100') — construction to the following:
10.Static water level below top of casing: 33 (tt,) 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 well
12.Well construction method: ry 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
5' Air 24c.For Water Supply&Injection Wills:
13a.Yield(gpm) Method of test:
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.
i
Form GW-I North Carolina Depattme9t of Environment and Natural Resources—Division of Water Resources Revised August 2013