GW1--07583_Well Construction - GW1_20231121

i ,
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Intbrntation:
Dwight L. Huneycutt FRWA TER TONES DESCRIPTION,
Well Contractor Name 90 ft- 93 ft- I : 10 gpm ,
4070-A - 96 ft- 101 ft- 5)gpm (109-114'=45gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) .
FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 87 ft- 61/8 !in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
383594 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in. .
List all applicable well permits(i.e.Counry,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
ft. ft in.
0 Geothermal(Heatin fCooling Supply) ORtsidenti al Water Supply(single)
❑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:
gMonitoring ❑Recovery 3 fc 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(color,hardness,soillrock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Rettun) ❑Other(explain under#21 Remarks) 0 ft- 21 ft. Red Dirt
4.Date Well(s)Completed: 6/7/23 Well ID# 21 • ft- 51 ft- Brown Dirt
51 ft- 79 ft' Junky Rock
5a.Well Location: 79 ft- 125 ft' Blue Granite
Rebecca&Millard Bost ft. ft.
Facility/Owner Name Facility Ib//(if applicable)
ft.
ft- Seams:90-93'=10gpm,96-101'=5gpm,
40978 Hearne Rd, New London 28127
ft. ft. 109-114'=45gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 12114 ' `s. t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: N O V ? 21'ZJ
(if well field,one lat/long is sufficient) 22.Certification: / ^
�Gz��� ;,6%28%231ia"i
N W
Signature of C fied Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary i
By signing this form,I hereby cert fy that;the wells)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 ❑No copy of this record has been provided to die 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
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft) 24a. For All Wells: Submit this fonn 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:
20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
�24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 60 Method of test: Air f
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. I 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