GW1--07592_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.WATERZONES . ' I ''' -- -
g Y FROM TO DESCRIPTION
Well Contractor Name 172 f• 180 f• I 15 gpm
4070-A ft. ft. J
NC Well Contractor Certification Number 15.OUTER CASING.(for multi-cased wells)OR LINER(if ap linable) •
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o tt. 65 f• 61/8 in. SDR-21 PVC
Company Name • '16.INNER CASING OR TUBING(geothermal closed-loop) - '
384474 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. •B. "in-
3.Well Use(check well use): 17.SCREEN - - "
Water Supply Well: ` FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.
❑Agricultural ❑Municipal/Public ft. in.
• OGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) B.GROUT =
FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 f• Bent.Chips Gravity
Non-Water Supply Well: •
❑Monitoring ❑Recovery 3 f• 20 aBentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)' • -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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,soil/rork type,pain size,etc-)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft• 29 it Wet Red Clay
3/1/23 29 fr. 44 it Wet Brown Dirt'
4.Date Well(s)Completed: Well ID#
44 ft 56. ft' I, Soft Brown Rock
5a.Well Location: 56 ft 225 f• Blue Granite
Troy Arnette f• f•
Facility/Owner Name Facility iD#(if applicable) R f• Seams':89',95',117', 134',143',"172'=15g
13108E Mission Church Rd., Locust 28097 (Lot 1)
it. ft.
Physical Address,City,and Zip • 21.REMARKS - -- ." f; ?• ='''S
Stanly 14386 e -y,,.. °; a Tii7•i ".;i3
County Parcel Identification No.(PIN) .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) Int
N W '^Ulu 1
Signature of rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A 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 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
submit one form. SUBMITTAL INSTUCTIONS
I.
9.Total well depth below land surface: 225 (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(4)100) 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 Mall Service Center,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 form'within 30 days of completion of well
12.Well construction method: rY construction to the following: 1(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) 15 Method of test: Air 24c.For Water Supply&Injection Wells:
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