GW1--07584_Well Construction - GW1_20231121

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
•
This form can be used for single or multiple wells
1.Well Contractor Information: ,
14.FROM TO
John W. Huneycutt
FROM TO DESCRIPTION
Well Contractor Name 97 ft- 105 ft, 1 1. 10 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. - • o ft 69 ft- 61/8 i• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
379875 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft + in,
List all applicable well permits(i.e.County,Stale,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 ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft in
Olndustrial/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:
❑Monitoring ❑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)
0 Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 40 ft- Brown Dirt&Rock
5/2/23 40 ft- 265 ft- 1 Shale&Blue Rock
4,Date Well(s)Completed: Well ID# ft. ft. '
•
5a.Well Location: ft. ft.
Sera Phillips ft. ft.
• Seams:75',90',97-105'=10gpm,
Facility/Owner Name Facility ID!!(if applicable) ft ft.
Old Whitney Rd., New LOndon 28127 ft. ft. 125', 151'.
1.
• Physical Address,City,and Zip 21.REMARKS I. r. ' }.i a I '
Stanly 11580 �'aa ' G`" ' - -
County Parcel Identification No.(PIN) N O V . t Lu 23
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ^-.:.--11
(if well field,one tat/long is sufficient) ^it �'
N 'w
�GZ I `.[ �. ��` 5f22%z3 •
Signature of ertified Well Contractor Date
6.Is(are)the well(s): I27Permanent or ❑Temporary By signing this form,I hereby cerdty thai the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 102C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or DNo 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 421 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iidiifferent(example-3@200'and 2@I00') construction to the following: 1
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 29 (ft.)
Ifwater level is above casing,use"+" 1617 Mail Service Cei ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above,also submit a copy of this foim 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
13a.Yield(gpm) 10 Method of test: Air
24c.For Water Supply&Injection Melds:
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 Resources Revised August 2013