GW1--07577_Well Construction - GW1_20231121

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.WATER ZONES 1FROM TO DESCRIPTION
Well Contractor Name 109 ft. 112' ft• I ; 3 gpm ,
4070-A 168 ft• 175 ft. 12 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if applicable)
FROM TO • DIAMETER . 'THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 52 ft• 61/8 I; SDR-21 l PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
366812 FROM TO , DIAMETER • THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well permits(1.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
ft. ft. in.
❑Agricultural OMunicipal/Public .
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 It. Bent.Chips Gravity .
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 IIBentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑SubsldenCe Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM ' TO DESCRIPTION(color,hardness,soil/rock type.grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. Red Dirt
4.Date Well(s)Completed: 7/19/23 Well ID# 6 ft 18 f6 Brown Dirt-
18 ft• 33 ft. Brown Rock
5a.Well Location:
Ka cie McKibben 33 ft. 300 . f6 Slate
y ft. f4
Facility/Owner Name Facility ID#(if applicable)
ft. ff Seams:88',97', 109'=3gpm,131', 156',
US Hwy 52, Norwood 28128
168-2gpm,198 2.1,3.,.229
• Physical Address,City,and Zip 21.1tEML1RK5
Stanly 5635
County Parcel Identification No.(PIN) i' NUV 2 j 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: , l� J
22.Certification: Ir s�;;^` ^1 - ':
�G
(if well field,one lat/long is sufficient) / -.^. ;;?
. n, � tin
N W tt[ .L.
7V11.07Gaet 'A"7/31123,
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPerrnanent or ❑Temporary By signing this form,I hereby certify tha(the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes 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#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 i
submit one form. SUBMITTAL INSTUCTIONS 1 •
•9.Total well depth below land surface: 300 (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: (,
30 Division of Water Resources,Information Promssing Unit,
10.Static water level below top of casing: (ft.) Division
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I '
11.Borehole diameter: 6 (in.) 24b.For Iniectiort 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 Cen ter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 8 Method of test: Air Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount 1/2 Ib• 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