GW1--05001_Well Construction - GW1_20230807

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 DESCRIPTION I
Well Contractor Name -~ tr-.%_„ 64 ft. 68 fL 10 gpm
2465-A 73 ft. 76 j 5 gpm
NC Well Contractor Certification Number A U G 0 7 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER, THICKNESS MATERIAL •
Derry's Well Drilling, Inc. .ma,; o ft. 45 fw 61/8 iry SCR-21 PVC
Company Name IWW0/.204:3 16.INNER CASING OR TUBING(geothermal closed-loop) '
372699 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. 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
❑Agricultural ❑Municipal/Public H. H. in.
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft' ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ORecovery 3 ft- 20 fr. Bentonite Pumped
Injection Well: ft. ft. •
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(it applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
0 Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 3 ft. Brown Dirt
ft
4.Date Well(s)Completed: 2/6/23 Well ID# 3 WO ft* Blue Rock
H. H. ,
5a.Well Location: ft. ft.
Larry A. Thompson f4 ft. eams:58',64'=10gpm,73'=5gpm,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 90',95'
36754 Cooper Rd., Norwood 28128 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 31627
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N Wg*JJ'P a).
jiy(// 2/20/23
Signat of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 1421 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 fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 00 (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: 26 (ft.) Division of Water Resources,Information Processing Unit,
If water 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 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) 15 „ Method of test: Air ��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. wellconstructionthe county
to oty health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I ,