GW1--05152_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
I
This form can be used for single or multiple wells
I.Well Contractor information:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 50 ft. 54 ft. 1 gpm (165-170'=1 gpm)
2465-A 350 rt. 389 ft. 1 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 45 ft- 61/8 1n' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
371959 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
DAgricultural ❑Municipal/Public ft. ft. in.
ft' ft. 1O'❑Geothermal(Heating/Cooling Supply) iDRcsidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 25 ft. Brown Dirt
4.Date Well(s)Completed: 5/18/24 Well ID# 25 ft' 400 ft. Slate
ft. ft.
5a.Well Location: ft. ft.
Venture 8 Property Experts LLC ft. ft. Seams:47', 50-54'=1g, 147', 165'=1g,
Facility/Owner Name Facility iD#(if applicable) ft. ft. 200',248',292',350-389'=1g
Coyle Rd., Stanfield 28104 (Lot 3) ft. ft. -__ -
Physical Address,City,and Zip 21.REMARKS ,y s. f,"
Stanly 137646 '+ °�
County Parcel Identification No.(PIN) AU G e► 0 [G24
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: If,.r;,: _ - ,. -•
(if well field,one lat/long is sufficient) / •
N W
Si ure of Certified Well Contractor Date
6.Is(are)the well(s): ElPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA 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#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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (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@i00') 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
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) 3 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