GW1--07574_Well Construction - GW1_20231121

r
1
I
WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Weil Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES I "-'' . - ' • - .- -
9 Y FROM TO DESCRIPTION
Well Contractor Name 67 ft 75 ft I 100 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.-OUTER CASING(for multi-cased wells)OR LINER(if ap licahle) -
FROM TO. DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 58 ft 6 1/8 !in- SDR-21 PVC
Company Name -16.INNER CASING OR TUBING-(geothermal closed-loop) - ".
367087 FROM TO DIAMETER , THICKNESS MATERIAL
2.Well Construction Permit#: ft. 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 ❑Mumicipal/Public in.
OGeothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1ti.GROUT =
FROM TO MATERIAL'S EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 ft. Bentonite Pumped
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
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) - -,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(calor,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 42 ft. Wet Red Clay
2/28/23 42 f6 50 ft. ' Soft Brown Rock
4.Date Well(s)Completed: Well DM
50 f° 100 ft I Blue Granite
5a.Well Location: ft. ft.
Troy Amette
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams:•63',67-75'=100gpm,89',95'
ft. ft.
13108E Mission Church Rd., Locust 28097 (Lot 4)
ft. ft. .
Physical Address,City,and Zip ' "'Z.''i 1.` l +
21.REMARKS - -
Stanly 14386 NOV 9, 12023
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in d utes/seconds or decimal degrees: r' '°'"" ` ~ `-=-="•i'n ice2 gi degrees/minutes/seconds egr 22.Certification: DVIIi�._',0..:1 '� .t
(if well field,one lat/long is sufficient)
v
N W Z7(41 �� or r&tc— 3/15/23
Signature o ertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby cert fy that the wells)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 ONo 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#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 seine construction,you can I, '
submit one form. SUBMITTAL INSTUCTIONS P
9.Total well depth below land surface: 100 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (m) Division of Water Resources,'Information Processing Unit,
Ifseater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: In Iaddition to sending the form to the address in
Rota 24a above, also submit a copy of thisF form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(ie.anger,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 00 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 ResouIrces Revised August 2013
I