GW1--05139_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WMATER ZONESFRO TO DESCRIPTION
Well Contractor Name 114 ft. 117 ft. 4 gpm
4070-A rt. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 64 re- 6 1/8 'n• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
401092 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 ❑MunicipalPublic Ft. ft. in.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
❑Irrigation 0 ft. 3 R 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
tY. • k.
❑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.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 Ft. 17 ft. Red Clay
2/15/24 17 ft' 43 ft* Brown Dirt
4.Date Well(s)Completed: Well ION
43 ft• 55 ft Brown Rock
5a.Well Location: 55 ft* 285 It Slate
Josh Amick ft. n•
Seams:74', 109', 114'=4g, 175', 190'
Facility/Owner Name Facility 1D4(if applicable)
ft. ft.
Riverview Rd., Norwood 28128 (Lt 3) rt. rt.
-- _ _
Physical Address,City,and Zip 21.REMARKS v.., �. a
Stanly 142352
County Parcel Identification No.(PIN) n U l]J� / `� �i
J 9 t?.�
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification• I i- --; ?--..,
(if well field,one lat/long is sufficient) 1� C1"!, , ,I'' .' Beet
N W
Contractor
G 7e72$'
Signature of enified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02(7.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or llNo 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#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
S.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 cotrstructloa,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (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 (B,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.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(gpm) 4 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