GW1--05010_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Infoation:
DwI ht L. Huneycutt 14.WATER ZONES t
9 FROM TO DESCRIPTION I
Well Contractor Name . _ _ 299 ft. 305 ft. 1 gpm
4070-A F ✓C. ` r"- fr. ft.
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
7 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. AUG 6 L o ft• 52 ft• 6 1/8 SDR-21 PVC
Company Name Inform-AU-cm ?r^..7; J,0 ura 16.FROM INNER CASING OR TUBING
(gERhermal1clloossed-loo )CKNESS MATERIAL
2.Well Construction Permit#: 119756 D + a o ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. ft ft. in.
OAgricultural ❑Municipal/Public
ft fr in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
•
0 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)
❑A uifer Storage and Recovery ❑Salini Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
9 g ty ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,harness,soiVrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it. 16 ft. Brown Dirt/Rock
4/18/23 16 ft• 500 ft• Slate
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
Tom Huiet ft.
Seams:61',75',89', 112',134', 167',204',
Facility/Owner Name Facility ID#(if applicable)
ft ft. 250',299'=lgpm,313',355',392',
Rocky River Springs Rd, Norwood 28128 ft. ft. 415'
Physical Address,City,and Zip 21.REMARKS ,
Stanly 13653
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 W Z u ail tL, 5/5/23
Signature f Certified Well Contractor Date
6.Is(are)the well(s): 1/lPermanent or ❑Temporary By signing this form,1 hereby certtry that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or EINo 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 1121 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: 500 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing: 59 (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 Infection 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: f y 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) 1 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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