GW1--01905_Well Construction - GW1_20240325

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
\, This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt r' ;,o 1--,w,:1 Yt.;.-�r 14.WATER ZONES 1
`�'�,;.rT• „ k`.=•,i t ,,.,,-.J FROM TO DESCRIPTION
Well Contractor Name '' " �"'"�`' 133 ft 135 ft 15 gpm (312-315'=3gpm)
4070-A MAR 2 _` 2024 396 f- 402 ft- I , 12 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ink; :,:D P,...,^ 44,: u?. FROM TO DIAMETER! THICKNESS MATERIAL
Derry's Well Drilling, Inc. D-W018-,DG 0 ft. 45 ft 61/8 I 1D• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop).
261046 FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft t ;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 ❑MunicipallPublic ft ft. in.:
i
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation • 0 ft. 3 ft. BentLChips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO AATERIA ft. ft. , EMPLACEMENT METHOD
_
❑Aquifer Test ❑Stormwater Drainage
ft. ft. '
❑Experimental Technology OSubsidence Control '
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft.. 9 ft Red Dirt
8/26/23 9 'I' 23 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
• 23 ft 425 ft Slate
5a.Well Location:
ft ft
Christopher&Carrie Charest . ft. , ,_ ,_
Facility/Owner Name Facility ID#(if applicable) Seams:I 131, 133=5g, 174,210',312=3g,
ft.
t ft
6025 River Rd., Richfield 28137 ft. 375',396-402'=12g
ft.
Physical Address,City,and Zip
21.REMARKS `
Rowan 548 035
.
County Parcel Identification No.(PIN) I;
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W P � 9/2/23
Signature of C ed Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary '
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1SA 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 EINo copy of this record has been provided to the ivell 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: 425 (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: 1.
30 Division of Water Resourees,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing use"+" 1617 Mail 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
Rotary24a 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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