GW1--05153_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:
John W. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 101 IL 104 ft. 1 gpm (230-235'=2 gpm)
2465-A 310 ft• 316 ft 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a Ruble)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 56 fL 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
390545 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
OAgricultural OMunicipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL in
❑lndustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM J 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
0 Aquifer Test OStormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control T
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain stet,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 40 ft. Brown Dirt
4.Date Well(s)Completed: 5/3/24 Well DM40 ft 50 fL Shale
50 fL 325 ft. Slate
5a.Well Location: ft. ft.
David Smith ft ft
Seams:56',74',83',87',97', 101'=1 g,
Facility/Owner Name Facility ID#(if applicable)
ft. ft. 115', 125', 130', 155', 178', 196',205',
24493 Ridgecrest Rd., Locust 28097 ft. ft.
212',221',230'=2g,250',285',310'=3g
Physical Address,City,and Zip 21.REMARKS - - . _
Stanly 465 6 - ' ' ,
County Parcel Identification No.(PIN) (;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: A�i G v 0 C!74
22.Certification:
(if well field,one lat/long is sufficient) /
N W d/LJL W.f7/7 ltrr,..,.,_: ' `$ll•V2 .7:+
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): lZPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 ONo 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 r,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: 325 (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 Iniection 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 m 6 Method of test: Air 24c.For Water Supply&Injection Wells:
(gpm) 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013