GW1--05149_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
I
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 192 ft- 196 ft- 4 gpm
2465-A ft. ft.
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• 74 ft• 6 1/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
402083 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 ft ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply ft. ft. 1O
g/ g PP Y) PP Y(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
❑Irrigation 0 ft. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicably
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -,
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 40 ft• Brown Dirt
4.Date Well(s)Completed: 5/9/24 Well ID# 40 69 ft' Brown Rock
69 ft- 305 ft- Slate
5a.Well Location: ft. ft.
Reese Gibson ft.
Seams: 78,92,103, 118, 135, 192=4g
Facility/Owner Name Facility 1DR(if applicable)
11730 Gibson River Tr., Stanfield 28163 (Lot 8) ft. ft. 235',275'
ft. ft.
Physical Address,City,and Zip
21.REMARKS I ,
Stanly 137439
County Parcel Identification No.(PIN) ",I (I O g n 2 i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) //
N W
44,
a
a/. ` •" ..5/ 9/24
Si of Certified Well Contractor D' Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 ]No 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
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: 305 (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 (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 lniection 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