GW1--02004_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt �o ATERZONES DESCRIPTION
CRIPTTN
Well Contractor Name 49 ft 50 ft• 2 gpm
4070-A 51 ft. 53 ft , , 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 44 ft. 61/8 "S SDR-21 I PVC
Company Name - 16.INNER CASING OR TUBING(geothermal closed-loop)
371516 FROM TO DIAMETER 1 THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits(i.e.County,State,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 i
❑Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft is in
❑Industriall m Cotnercial ❑Residential Water Supply(shared) is.'GROUT - .
FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 n 3 ft Bent.Chips, Gravity
Non-Water Supply Well: 3 ft. 20 ft Bentonite;• : Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft. I.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL 1 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)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 21 ft i Brown Dirt/Rock
11/3/23 21 ft. 280 ft !, Slate
4.Date Well(s)Completed: Well ID# ft. ft ''
I, •
5a.Well Location: • ft. ft. I.
Richard Beck
ft. ft Seams:;49'=2g,51-53'=4g,75',93', 132'
Facility/Owner Name Facility ID#(if applicable)
Love Mill Rd., Stanfield (Lot 1) f ft ! 150', 153', 176',272'
ft H.
Physical Address,City,and Zip 2L REMARKS ' - :` [" Jr--, •N" n PI" r4
Stanly 20568 j 1 1, Le a._i; V a_i
County Parcel Identification No.(PIN) 1 , APR 1? 1 21174
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I. • l(
(if well field,one lat/long is sufficient) nr-,C V;nA2 L nX
�G4r � tnGCl�r f3i1 • 0/23
N W
oftd Well Contractor 1 Date
6.Is(are)the well(s): 17Permanent or ❑Temporary
By signing this form,I hereby certity that the well(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 EINo copy of this record has been provided to the,veil owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#2I 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: 280 (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@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 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:
(ie.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) 6 Method of test: Air
24c.For Water Supply&Injection We lls:
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