GW1-2021-05815_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name r 02, 170 ft- 180 ft- 30 gpm
J0- `L0 ft. ft.
4070-A U
NC Well Contractor Certification Number sg�n9 1s lti
FROMUTER,rG for rouDIAMETEReits OR ���a h MATERIAL
Derry's Well Drilling, Inc. I ��Sw;o� 0 ft 46 tt• 61/8 i" SDR-21 I PVC
Company Natne 16.INNER CASING OR TUBING eothermal closed-loop)
334429 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(i.e.County,State,Variance,injection,eie.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a iicable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. O.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardnen,soiltroek tyM grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 14 ft Brown Dirt Rock
5/24/21 14 ft- 200 ft- Slate
4.Date Well(s)Completed: Well iD# ft. ft.
5a.Well Location: ft. ft.
Austin M Lambert&Maday Miller ft fit.
Facility/Owner Name Facility iD#(if applicable)
ft. ft. Seams: 170'=30g
Miller Rd., Richfield 28137
ft. ft
Physical Address,City.and Zip 21.REMARKS
Stanly 139926
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification-
(ifwell field.ate Iat/long is sufficient)
N W
J�{t/ 6/10/21
Signature ot'Certitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By.signing this form,I hereby certify that the we//(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy tf this record has been provided to the well(comer.
/f this is a repair,fill out known well construction information and explain the nature of the
repair under 121 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SITBMITTALINST TCTiONS
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9.Total well depth below land surface'. 200 (ft.) 24a. For All Wells: Submit this'foim within 30 days of completion of well
Por multiple wells list all depths ifdifferent(example-3(200'and 1Q100') construction to the following:
10.Static water level below top of casing: 28 (ft) Division of Water Resources,information Processing Unit,
/'water level is above casing,use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter. 6 (in.) 24b.For injection Wells ONLY: 'tin 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 27699-16M
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13a.field(gpm) 30 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 RI sources Revised August 2013
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