GW1--07585_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
g Y FROM TO DESCRIPTIONI
Well Contractor Name 114 it 118 ft• I 4 gpm
4070-A 156 ft. 160 ft. I 4 gpm
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' 108 it 61/8 :in! SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
380174 FROM . TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. 'in.
List all applicable well permits(i.e.County State,Variance,.Injection,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft tt io
•
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation O ft. 3 ft. Bent.Chips Gravity .
Non-Water Supply Well: .
❑Monitoring ❑Recovery 3 ft• 20 ft. Bentonite Pumped
Injection Well: ft. ft. I'
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
❑Aquifer Test OStormwater Drainage ft. ff.
❑Experimental Technology 0 Subsidence Control .
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) . ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 38 ,ft. I ' Wet Brown Dirt
4.Date Well(s)Completed: 2/27/23 Well ID# 38 ft 95 ft Junky Quartz&Brown Rock
95 f• 265 ft. r Blue Granite
5a.Well Location: ft. ft. I
Troy Arnette
Facility/Owner Name Facility 11)4(if applicable) ft. ft SearriS: 114'=4g, 129', 148', 156'=4g
ft. ft.
13108B Mission Church Rd., Locust 28097 (Lot 2) ft. ft. • — _-
Physical Address,City,and Zip 21.REMARKS v..--'�.,,s.._ , ,. i f §mf
Stanly 14386 NOV 2
County Parcel Identification No.(PIN)
t 2023
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: z2,Certification: In';;'r. i^n P =°'':!-10li;;'Q
(if well field,one lat/long is sufficient) ! D',.q:i,' `)`.1
• N �, �GZ � 3/15/23
Signature oftertified Well Contractor Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,1 hereby certtbi!ba/the wells)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 ElNo copy of this record has been provided to this well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under il21 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 conslru tlon,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 if different(example-3(200'and 2@I00) construction to the following: '
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Ce i 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
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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,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 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