GW1-2021-05808_Well Construction - GW1_20210709

4
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 8�
Dwight L. Huneycutt RE 1144.WATER TOFRO DEscRiPT1oN
Well Contractor Name I 1 I O 75 ant' 280 n' 3 gpm
4070-A JUL
Illt n
NC Well Contractor Certification Nu nber iO1r`(rr.3t10t�n ppI01'@$S 1 .OUTER CASING for multitased wells OR LINER d a licable
n`ryt�,Cje(`,�i0 FROM TO DIAMETER ! 'THICKNESS MAI•PRrei.
Derry's Well Drilling, Inc. I,y 0 n 66 ft 6 1/8 '° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
354207 FROM TO DIAMETER THICEG�ESS MATERIAL
2.Well Construction Permit#: n. n. '°•
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
n. n. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
n n. in.
❑Agricultural ❑Municipal/Public
ft n' in.
❑Geothermal(Heating/CoolingSupply) ®Residential Water SuPP1Y(single)
❑Industrial/Conirnercial ❑Residential Water Supply(shared) is.GROUT
FRODI TO AfATFRiei. 1sM7IACEIITENT METHOD&AMOUNT
❑hri ation 0 n' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
3 n' 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL ENIPLACEMENr METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n. n.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soi0rock type,grain size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 17 rt. Red Dirt
3/25/21 17 n. 48 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
48 n 345 ft• Slate
59.Well Location:
Joy Hildreth
Facility/Owner Name Facility ID#(if applicable)
6545 Whitley Rd, Norwood 28128 a. Seams:85', 114', 178,234',275'=3g
Physical Address,City,and Zip 21 REMARKS
Stanly 25011
County Parcel Identification No.(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) /
N W ,[r, uy+ 4/21/21
Signature of nified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the.vell(s)it-as(ivere)constructed in accordance
with I SA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Constniction 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 ivell owner.
If this is a repair,fill out known well constrnction information and explain the nature of the
repair tinder#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: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,veils list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+^ 1617 Mail Service Cent er,'Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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) 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 Ib.
well construction to the county health department of the county where
constructed.
Fonn GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
!Y
I