GW1-2021-05816_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY: I
This form can be used for single or multiple wells V
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO1 DESCRIPTION
Well Contractor Name g 76 ft. 80 ft. 2 gpm
2465-A 0 9 2�21 210 ft. 216 ft. 8 gpm
NC Well Contractor Certification Number 1 uL 15.OUTER Er for malti-cased wells)OR LINER ifs licable
J FROM TO DIAMETER TAIC[�ESS MATERIAL
Derry's Well Drilling, Inc. "essin9U 'Oft- 66 ft 61/8 SDR-21 PVC
Company Name +R Sec!'0 16.1NNER CASING OR TUBING(geothermal closed-loci
270847 V t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well permits(ie.County,Slate,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT STZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. % in,
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. is
01ndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT '
FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 e. 3 It- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 14.SANDiGRAVEL PACK if a icable
❑Aquifer Storage and Recovery []Salinity Barrier FROM ft. TO
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage D ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if aeccssa '
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness soiltrock tyM grainsiee,tic
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 19 ft Red Dirt
5/24/21 19 ft- 245 ft- Slate
4.Date Well(s)Completed: Well fl)#
ft ft
5a.Well Location: ft ft.
Paul Swan ft ft.
Facility/Owner Name Facility iD#(if applicable) fL ft.16063 McLester Rd., Oakboro 28129 Seams:76'=2g, 159',210'=8g
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 6451
Comity Parcel identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W , 6/10/21
Sign ol'Certified Well Contractor Date
6.Is(are)the well(s): 101ermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)conducted 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 EINo copy ofthis record has been provided to the well turner.
If thie is a repair,fill our known[Pell construction information and explain the nature of the
repair under ii21 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
SUBMITTAL iNSTiJCTiONS
submit one forth
9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this Mono within 30 days of completion of well
Nor multiple wells list all depths tfd6Terent(example-3@200'and 2a 100) construction to the following:
10.Static water level below top of easing: 28 (ft) Division of Water Resources,information Processing Unit,
Ifwaierlevel 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: j
(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
13s.Yield(gpm) 10 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-I North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013
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