GW1--07581_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
DWI ht L. Huneycutt 14.WATER ZONES• _ '.l'
. ,g, Y FROM TO DESCRIPTION
Well ContractorName 414 ft' 418 ft• I 1/2 gpm
4070-A 435 ft. 440 ft- I 1/2 gpm
NC Well Contractor Certification Number AS.OUTER CASING(for mul METd w6 ells)OR ICNER(if ap licable)''
FROM TO MATERIAL
Derry's Well Drilling, Inc. o ft 45 ft 6 1/8 ;'i°• SDR-21 PVC
16.INNER CASING OR TUBING(>eothermal'closed-loop) 'w:. •°'
Company Name
388537 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ; in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft. ft <in.
3.Well Use(check well use):. 17.SCREENi "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS .MATERIAL
ft ft. in.
®Agricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt, ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 it 3 ft• Beni Cliips Gravity,
Non-Water Supply Well:
:Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft. i'
❑Aquifer Recharge ❑Groundwater Remediation `t9:SAND/GRAVEL-PACK(if applicable) '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ' ft. i '
OAquifer Test ❑Stormwater Drainage ft. ft
❑EXperimental Technology OSubsidence Control I.
DRILLING LOG(attach additionalslieets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
❑Geothermab(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 16 ft 1 Brown Dirt&.Rock
5/22/23 16 ft 465 ft Slate
4.Date Well(s)Completed: Well ID# ^
ft ft. 1'
5a.Well Location: ft ft.
Tom Huiet ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft t •
Seams: 112,134, 175,212,287,323,
Southern Rd, Nowood 28128
It. ft. 377',414'=1/2gpm,435'=1/2gpm
Physical Address,City,and Zip 21:REMARKS,
Stanly 12502 I' {
County Parcel Identification No.(PIN) •
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: N O V 2 t 2023
22,Certification:
(if well field,one lat/long is sufficient)
Signature of rtified Well Contractor '''''-Date.'
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certiry that the well(s)was(were)constructed in accordance
with 15A 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 ElNo 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 I
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: 465 (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@I00) construction to the following:
10.Static water level below top of casing: 38 (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 infection Wells ONLY: In addition to sending the form to the address in
Rota 24aabove, also submit a copy of ails'form within 30 days of completion of well
12.Well construction method: Rotary 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: Alr 24c.For Water Supply&Injection Wells:
Also submit one copy of this forml 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-I North Carolina Department of Environment and Natural Resources—Division of Water R ources Revised August 2013