GW1--05003_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name / A, A� 175 ft- 180 • ft, 12gpm
4070-A t r 6..f d`hi�E ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
AUG 0 7 2023 FROM TO DIAMETER' I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 82 ft. 61/8 iin'; SDR-21 PVC
Company Name IfliCi:f r.'^.Il i5Tr:-G97441,D Unit 16.INNER CASING OR TUBING(geothermal closed-loop)
366734 D1�v`Cb ri(.-'a FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ,in.
List all applicable well permits(Le.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 a ft in.
ft❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft rn
❑Industrial/Commercial ❑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 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT11iETHOD
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 DESCRIPTION(color,hardness,soilirock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 19 ft- Red Dirt
4.Date Well(s)Completed: 12/31/22 Well ID# 19 ft 56 ft Brown Dirt
56 ft- 73 ft- Brown Rock
5a.Well Location: 73 ft- 185 ft- Slate
•
WR Contracting& Design ft. ft.
Facility/Owner Name Facility Mil(if applicable)
ft. ft. Seams:91',97', 114', 122', 136', 143',
Running Creek Church Rd, Locust 28097 ft. ft. ,_
148, 151, 175-12gpm
Physical Address,City,and Zip 21.REMARKS `
Stanly 140555
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latilong is sufficient) //
N W T7GU� �L. 1/15/23
Signature of ertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(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 ENo 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#2I 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: 185 (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@I00') construction to the following:
10.Static water level below top of casing 35 (it) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection 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) 12 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 Resources Revised August 2013