GW1--05009_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: '
Dwight L. Huneycutt 14.WATERZONES' _
9 y FROM TO DESCRIPTION
Well Contractor Name 312 ft, 315 ft 1 ' 1 gpm
4070-A ;::..r t 414 R. 420 ft I [ 1 gpm
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)'OR LINER(if ap limbic)
AUG �o�� FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. U 7 - 0 ft. 50 ft 6 1/8 in• SDR-21 PVC
Company Name n 7 r o 16.INNER CASING OR TUBING(geothermal closed-loop) ' -
11t 4 `/ / Cxr ~ .9 U!i FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: O.-0/13 X ft. ft. in.
list all applicable well permits(Ie.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
ft. ft. in.
:Agricultural ❑Municjpalli'ublic - - _. _
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft irr
❑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.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)_=
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
-
❑Experimental Technology ID Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) - .-
0 Geothermal(Closed Loop) ❑Tracer FROM _ TO , DESCRIPTION(color,hardness,sail/rock type,grain sue,etc.)
❑Geothennal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 ft, 18 ft, Brown Dirt&Rock
4/20/23 18 ft 445 fr. Slate
4.Date Well(s)Completed: Well 1D# ft. ft.
5a.Well Location: ft. ft.
Lesa Brock __ a - ft- Seams:194',206',209',256',312'=1gpm,
Facility/Owner Name Facility 11)11(if applicable)
36179 Chapel Rd, Norwood 28128 388',409',414'=1gpm,431'
Physical Address,City,and Zip
21.REMARKS' -
Stanly 2669
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lot/king is sufficient)
N w .Z7GU� L 4/30/23
Signature of ettified Well Contactor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary By signing this form,I hereby cert fy 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.Ts 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 it formation 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: 445 (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: 34 (ft,) Division of Water Resources,Information Processing knit,
If water 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
2 Air 24c.For Water Supply&Injection Wells:
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 h 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
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