GW1--05136_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 230 ft• 234 ft 10 gpm
4070-A 261 ft 265 ft 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft. 61/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
400758 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 OMunicipal/Public a. ft is
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) rt ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I.s.GROUT
FROM TO MATERIAL 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.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
—
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rack type,dais size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 21 R. Brown Dirt&Rock
4.Date Well(s)Completed: 3/18/24 Well IDk 21 - 285 fit. Gray Granite
ft. ft.
5a.Well Location: ft. R.
Cody Mullis n• ft
Seams:62',79', 170', 191',230-234'=10g,
Facility/Owner Name Facility ID#(if applicable)
9704A Fred Rd., Stanfield 28163 ft ft 261'=2g
rt ft
Physical Address,City,and Zip 21.REMARKS r^ - ,
Stanly 142365 b '
County Parcel Identification No.(PIN) AUG J 624
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Signature o Certified Well Contractor Date
6.Is(are)the well(s): OPerntanent or ❑Temporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance
with/5A NCAC 02C.0100 or 1SA NCAC 01(:'.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
repair under x21 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 ON/.Y with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 at,) 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,
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
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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
12 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