GW1-2021-05819_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 Namc 236 ft. 245 ft- 30 gpm
4070-A 1 O 9 2021 ft. It.
NC Well Contractor Certification Number JUL 15.OUTER CASING for multi-cased,wells OR LINER if a licable
uhl� FROM TO DIAMETER THIC[OVESS MATE[tlAl
Derry's Well Drilling, Inc. ffVA3 n plOcesSln9 0 ft. 62 ft- 61/8 I" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(Reothelmal closed-loop)
328211 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(t.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.FVell Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
❑�Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft, in.
❑industrial/Commercial ❑Residential Water Supply(shared) 13,GROUT
FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 3 It. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 IL 35 ft- Bentonite Pumped
-injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK Ifa licable
FROM I TO I MATERIAL EMPLACEMENT PIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
❑Aquifer Test ❑Stormwater Drainage
tr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color.bardnps soalroek tym grain Size,etc
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft- 34 ft Brown Dirt
4.Date Well(s)Completed: 6/8/21 Well iIM 34 f`- 52 ft. Brown Rock
52 ft- 250 ft- Slate
5a.Well Location: ft. ft.
Thurman Burleson&Sons Farm rn ft.
Facility/Owner Name Facility lD#(ifapplicable) ft ft Seams:70',83',90', 105, 123', 137',
Kendalls Church Rd, Richfield 28137
ft. ft. 189', 193%230',236'=30g
Physical Address,City,and Zip 21.REMARKS
Stanly 31259
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification
(ifwell field,one lattlong is sufficient)
6/30/21
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Signature of Certified Well Contractor Date
6.Is(are)the well(S): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was 6vere)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 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:21 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.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCfiONS
9.Total well depth below land surface: 250 (It.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdijfereni(example-3@200'and 2 r@100') construction to the following:
10.Static water level below top of easing: 45 (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 Injection 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:
(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
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13a.Yield(gpm) 30 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. `
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Form OW-1 North Carolina Department of Environment and Natural Resources-Division of grater Resources '. Revised August 2013