GW1-2021-04497_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells k
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ,��++ 317 r` 321 r`' 3 gpm
4070-A V ft. rt. P
NC Well Contractor Certification Number 9 1,021 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. P resg\n9un� 0 It- 150 It- 6 1/8 in SDR-21 I PVC
Company Name �OwR a0n 16.INNER CASING OR TUBING(geothermal closed-loop)
�M3 J� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 291��� in.
List all applicable ivell permits(i.e.CounnS 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
ft. f. in.
❑Geotherral(Hcatin Coolin Supply) OResidential Water Supply(sin(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD At AMOUNT
❑Irri ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 r` 35 f`. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnn soil/rock type,Min size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Ctther(explain under#21 Remarks) 0 ft. 6 ft. Red Dirt
2/16/21 6 I`' 29 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
29 f` 38 f` Brown Rock
5a.Well Location:
38 ft' 340 ft. Slate
Marco Vega ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. Seams:69',95', 112',295',317'=3g
294 Carlie St., Norwood 28128 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Stanly 14693
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient) i/
l0 rV 3/1/21
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): G5Permanent or ❑Temporary By signing this form,I hereby certi,that,the srell(s)nws(it-ere)constructed in accordance
with 15A NCAC 02C.0100 or I SA NG9C',02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E3No capt,of this record has been provided to the well ouwer.
If this is a repair,full out knoim well construction information and explain the nature of the
repair under 421 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 uvells ONLY with the saute construction,poa con
sutbmit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 340 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifoFi fer•enr(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 39 Division of Water Resources,Information Processing Unit,
If,vater level 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
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.) 6
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f ;
13a.Yield(gpm) 3 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Re ottrces Revised August 2013
I
f
I