GW1--07594_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 = -. - ---I.- -
9 Y FROM TO DESCRIPTION
Well Contractor Name 430 ft 435 ft I 1 2 gpm
4070-A ft. ft j ; .
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. o ft 44 ft 61/8 la SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) - -- - . -
397726-2 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
[Agricultural OMunicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT =
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Rllrrigation 0 ft 3 It Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f- 20 it 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 0 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) ❑TIacer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sme,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 16 ft Brown Dirt
4.Date Well(s)Completed: $11$!23 Well ID# #2 16 ft 500 It Slate
•
ft. ft. ,
•
5a.Well Location: — ft. ft.
Charles Cline
Seams:70',430'=2gpm
Facility/Owner Name Facility ID#(if applicable)
ft ft.
107 Maple St., Locust 28097 ft. ft.
Physical Address,City,and Zip `+1
21:REMARKS _ . -`'>,
Stanly 2652
County Parcel Identification No.(PIN) N" 2 1 2023
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: •• •, l�
(if well field,one 1at/long is sufficient) l I''"' "n ,':?:v :.: l/h
(�� 1/7120-reet%.°'"' 9/2)23 J N W
Signature of C fied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certity that the we/1(s)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 0No 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 Ito provide additional well site details or well
8.Number of wells constructed: construction details..You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same constructor,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (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: 30 (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: I'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: {
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
2 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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