GW1--05013_Well Construction - GW1_20230807

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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
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
7 n.e ft. ft
2465-A ,,,d e:C i t VI-
. NC Well Contractor Certification Number A 15.OUTER CASING(for multi-cased wells)OR LINER(if ap G Mcable)
(� D
:1 7 2023 FROM TO DIAMETER. THICKNESS ATERIAL
Derry's Well Drilling, Inc. �/ ft. ft. in.
Company Name lnlv:,rT.`1^ 1 ?�r;^.�,rLs3 a c uDy 16.INNER CASING OR TUBING(geothermal closed-loop) -
119476 C��J vl'.'�i'vt,,i FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 77 ft 4 in. SCH40 PVC
List all applicable well permits(be.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.
❑Agricultural ❑MunicipalPublic ft• in.
❑Geothermal(Heating/Cooling Supply) lResidential Water Supply(single) ft in
l
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft- 77 a Concrete Gravity
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
FROM TO MATERIAL' ' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
R ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING-LOG(attach additional sheets if necessary). . -
El Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rack type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft.
3/22/23 ft. ft.
4.Date Well(s)Completed: Well ID#
ft ft.
5a.Well Location: ft. ft.
John Douglas Andrews ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
27058 Vintage Ln, Locust 28097 ft. ft.
Physical Address,City,and Zip •21.REMARKS '
Stanly 9008 4"PVC liner with packer was installed in an existing 6"well.
County Parcel Identification No.(PIN)
•
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W9.&14 a). ri/a7C4eZt-
5/5/23
Si of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: E]Yes or ❑No copy of this record has been provided to the ivell 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdeerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) 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
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) 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
I 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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