GW1--05040_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 94 ft. 98 f1 2 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap able)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft- 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400p)
400683 FROM TO DIAMETER 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 ❑Municipal/Public it. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft' ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 f• 3 it. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Rewvery 3 ft• 20 ft• Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Baer FROM TO MATERIAL EMPLACEMENT METHOD
Bath
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 sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 R. 9 ft• Red Dirt
4/10/24 9 ft 23 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
23 f• 31 ft. Brown Rock
5a.Well Location:
Steve Helms 31 k• 365 n- Gray Granite
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft.
t.
Stanfield 28163 ft. ft. Seams: 54',63',94'=2g, 102',277'
8588-B Renee Ford Rd., Stan
ft. f
Physical Address,City,and Zip
21.REMARKS t `w.... '0.. a `)1"',3..-
Stanly 142361
County Parcel Identification No.(PIN) AUG d 0 624
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: -,--
(dwell field,one lat/long is sufficient) If`3: r, •': '
.
N Gu>i✓yI 1J7,i.. '. J
5/1124
Signature o ertified Well Contractor ! Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,/hereby certify that the we'(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or I SA 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 well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under i2I 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: 365 (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 1@I00') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
If water 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
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:
(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 m 2 Method of test: Air 24c.For Water Supply&Injection Wells:
(gpm) 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