GW1--05142_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
9 Y FROM TO DESCRIPTION
Well Contractor Name 93 ft. 97 ft- 2 gpm (101-106'=3 gpm)
4070-A 198 ft 202 fi• 35 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o f4 54 ft. 6 1/8 lc'. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
371981 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 ❑MunicipaUPublic in.
❑Geothermal(Heating/Cooling Supply) FiResidential Water Supply(single) D ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 it- 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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 18 ft. Red Dirt
4.Date Well(s)Completed: 4u1'24 Well Mt( 18 ft• 43 ft• Brown Dirt
43 ft- 225 ft. Slate
5a.Well Location: ft ft.
Venture 8 Property Experts ft.
Seams:60',69',77',85',91',93-97'=2g,
Facility/Owner Name Facility IDtt(if applicable)
ft ft- 101-106'=3g, 198-202'=35g
Coyle Rd., Stanfield 28163 (Lot 12) ft ft
Physical Address,City,and Zip
21.REMARKS
Stanly 137646 - _.
County Parcel Identification No.(PIN) S. ii ,
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification: A UG I) 0 ZQ24
(if well field one lat/long is sufficient)
N W 77441f 1 4/25/21:.• ,
Signature of Certifieder Well Contractor D',•Uate` ' J' '
6.Is(are)the well(s): 21Permanent or ❑Temporary By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdifferent(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
13a.Yield(gpm) 40 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136 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