GW1-2021-05814_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal use ONLY: i
This form can be used for single or multiple wells
1,Well Contractor information:
DwtDwight L. Huneycutt 5 14.WATER ZONES
9 y B FROM TO DESCRIPTION'
Well Contractor Name �® 253 it 256 it' I ' 6 gpm
4070-A p g 2021 290 it 296 et• 24 gpm
NC Well Contractor Certification Number VO�� 15.OUTER CASING for multi cased wells OR LINER ifs licable
CDOeSStng FROM TO DIAMETER THICKNESS --
Derry's Well Drilling, Inc. tnlofm_ 10n P , ;0n 0 it' 49 ft- 6 1/8 'in SDR-21 PVC
ASP...
Company Name 16.INNER CASING OR TUBING(geothermal closed-woo
310092 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tr. tr. in.
List all applicable well permits(i.e.Counly,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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 it 3 i" Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recover}' 3 it- 35 It- Bentonite Pumped
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑AquiferStora Storage ❑Salim Barrier FROM To MATERIAL EMPLACEMENT METHOD
g Recovery �` ft. ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if uecessa
❑Geothelmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness sailfrock in sae,eta
❑Geothermal Heatin CoolingRetum ❑Other(explain under#21 Remarks} 0 ft- 15 ft Red Dirt
5/19/21 15 ft- 25 ft Brown Dirt
4,Date Well(s)Completed: Well il)# 25 ft 40 ft Brown Rock
5a.Well Location: 40 ft• 58 ft Slate
Colt& Misty Huneycutt fL
58 300 Granite
Facility/Owner Name Facility lD#(if applicable)
it tt Seams:52',58',70',80', 135',145',
44025 Snuggs Rd., Norwood 28128 ft. it 253'=6g,290'=24g
Physical Address,City,and Zip 21.REMARKS
Stanly 139715
Comity Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field.one lat/long is sufficient)
N W �l�UfL .L.. 6/10/21
Signature of rtified Well Contractor Date
6.Is(are)the well(S): ©Permanent or ❑Temporary Ry signing this form,1 hereby certify that'the weU(s)was(were)constructed in accordance
with 15A N(.AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill our known well construction informarron and explain the nature of the
repair under;r21 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.
Par multiple injection or non-wafer supply wells ONLY with the same construction,you can
submit one form SUBMITTAL TNSTTTCTTONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdijfereni(example-3@200'and 2 rt 100') construction to the following:
10.Static water level below top of casing: 27 (ft) Division of Water Resources,information Processing Unit,
ifwater 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
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
13a.Yield(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 Ib. well construction to the county health!department of the county where
constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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