GW1-2021-05818_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Tn[emal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
DWI
g y ®9���' FROM TO I DESCRIPTION
Well Contractor Name a 90 ft. 100 ft. 4 gpm
4070-A ft. f. i
15.OUTER CN for mulaed w ells)OTffiLN fa licableNCBellContractorCertificationNumber FROM DM hfATERIAI.
Derry's Well Drilling, Inc. IocesS�9 0 ft 45 ft- 61/8 i^ SDR-21 I PVC
Company Name 1�f01 "� �� t,6 16.INNER CASING OR TUBI NG(geothermal closed-loop) -
114629 D FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL fl. la
3.Well]Use(check well use): 17.SCREEN
Water Supply Krell• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft m.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD AMOUNT
❑irri ation 0 rt. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 35 rt• Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a l cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMP1ACEn>ENrDfETaop
[L ft.
❑Aquifer Test ❑Stormwater Drainage
[t. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necesse
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardans.soft/rock IyM grain size,etc
[]Geothermal Heating/CoolingRetum ❑Other(explain under#21 Remarks) 0 ft. 13 rt• Brown Dirt
4/16/21 13 rr 300 rt• Slate
4.Date Wells)Completed: Well iI)# ft. ft
5a.Well Location: ft. ft.
Carroll Braun ft. ft.
Facility/Owner Name Facility iD#(if applicable)
tr. rr_ Seams:72',90'=4g
Bethlehem Church Rd, Oakboro 28129 & &
Physical Address,City,and Zip 21.REMARKS
Stanly 12234
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one Iatrlong is sufficient) �
N
N 5/4/21
Signature of Certified Well Contractor V 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 ISA NC AC 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well em ner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under ii21 remarks section or on the back ofthis 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.
Par multiple injection or iron-water supply wells ONLY with the.same construction,you can
submit one form SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface- 300 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
]-or multiple wells list all depths ifdoerent(example-3(a3200'and tea 100') construction to the following:
10.Static water level below top of casing: 47 (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: iin 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: l(
(i.e.anger,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
132.Yield(gpm) 4 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. !I(
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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