GW1-2021-05817_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal Use ONLY: f p
This form can be used for single or multiple wells I
1.Well Contractor information: i
John W. Huneycutt F4.WATER ZONES
RROM TO DESCRIPTION
Well Contractor Name 250 fr. 257 fL 40 gpm
2465-A 0 9 2021 ft. ft
NC Well Contractor Certification Number Ju� ,� 15.OUTER CASING for malts cased wells OR(LINER if a licable
UO FROM TO DIAMETER THTC[flVESS MATERIAL
Derry's Well Drilling, Inc. p�cc�ssln9 0 fL 58 ft- 61/8 In SDR-21 I PVC
Company Name �1l DW 16.INNER CASING OR TUBING(geothermal closed-loop)
276793 FROM TO DIAMETER TMCKNFSS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well permits(ce.County,State,Variance,Injection,etc.)
ft. tt. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooting Supply) ❑Residential Water Supply(single) ft. ft
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Dlrri ation 0 ft. 3 rt- Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 fc Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a leable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIALEMPLACEMENT METHOD
[r. ft.
❑Aquifer Test ❑StormwaterDrainage rL tZ
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if rtecessa
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,baroness soil/rock •n sae,eta
❑Geothermal(Heatin CoolingRetum) ❑Other(explain under#21 Remarks) 0 fL 21 IL Brown Dirt
5/11/21 21 fL 260 ft• Slate
4.Date Wells)Completed: Well ID# ft tY
Sa.Well Location:
House Construction ft. f,
Facility/Owner Name Facility iD#(ifopplicable)16975 Randalls Ferry Rd, Norwood 28128 f FL L ft Seams:75�,9T, 108', 165',214,225',
Physical Address City,and Zip ft. ft 25o08 1
21.REMARKS
Stanly 30871
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
017well field,one lat/long is sufficient)
N WL!/. 6/1/21
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By.signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 END copy rfthis 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 ii2l remarks section or on the back oflhis 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.
Hor multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL WSTUCTiONS
9.Total well depth below land surface: 260 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3(200'and 2 a 100') construction to the following:
10,Static water level below top of casing. 21 (ft.) Division of Water Resources,information Processing Unit,
Ifwaterlevel is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 27699-1636
13a.Yield(gpm) 40 Method oftest• 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. If j
Form GW-i North Carolina Department of Environment and Natural Resources—Division of Water Resources i Revised August 2013
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