GW1--02006_Well Construction - GW1_20240401

WELL CONSTRUCTION RECORD For Internal Use ONLY: ! •
This form can be used for single or multiple wells I •
1.Well Contractor Information: • I
John W. Huneycutt 14.WATER ZONES' I
Y FROM TO DESCRIPTION I
Well Contractor Name 120 ft 140 ft- I 3 gpm
2465-A 225 ft- 235 ft I ; 47 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO - DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 48 ft 61/8 n- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
373890 FROM TO DIAMETER i i THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft fin.'
List all applicable well permits(i.e.County State,Variance,Injection,eta)• 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) ElResidential Water Supply(single) ft ft. �.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL r , EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM TO MATERIAL I 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/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft- . 1'. 'Brown Dirt&Rock
4.Date Well(s)Completed: 10/7/23 Well ID# 25 ft 240 ft Slate
ft. ft.
5a.Well Location: • ft ft.
Brittany Boone ft. ft
Seams:88,95', 108', 112',:120-140 120-140'=3gpm
Facility/Owner Name Facility IDil(if applicable)
-ft. ft. 172', 188,210',217',225-235'=47gpm
Loop Rd, Norwood 28128 ft. ft.
Physical Address,City,and Zip 4• Ty,.,��21.REMARKS !•� .,.: 7,... i.�_
Stanly 36643 ;,. s'...-`..<.,:T.'i `d,
County Parcel Identification No.(PIN) i
A Et
j .1 L��4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
\:::fi .
(if well field,one lat/long is sufficient) ', J i rlrt„rr,,,.,•, :, :; .
N W
W. urt�u G.J ,•.�.J�107 't. Sign),6•4p
of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certifi,that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes oc ENo 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 1/21 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 ! .
9.Total well depth below land surface: 240 (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 2Q100) construction to the following: i
I,
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 • (in.) 24b.For Infection 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 Cente p,Raleigh,NC 27699-1636
13a.Yield(gpm) 50 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 Iepartment of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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