GW1-2021-00845_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 1FA MATERZONES TO DESCR[MLON
Well Contractor Name 147 i1. 152 it' 4 gpm
2465-A n. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER d applicable
FROM TO DIAMETER. TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 iL 148 n 6 118 in SDR-21 PVC
Company Nave 16.INNER CASING OR TUBING(geothermal closed-loop)
119841 FROM TO DIAMETER I TIHCIdVESS MATERIAL
2.Well Construction Permit#: & n• in
List all applicable ivell permits(i.e.County,State,Variance,injection,etc.)
n. n. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIDCICQF.SS MATERIAL.
n. n. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
❑Induguial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO DIATERLAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 n. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 n' 35 n Bentonite Pumped
Injection Well:
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIMION color,hardness,som0rock qW,grain sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 n 15 n• Brown Dirt
7/8/21 15 n• 22 fL Brown Rock
4.Date Well(s)Completed: Well ID# 22 ft. 225 1" Slate
5a.Well Location: ft. ft.
Enterprise Rendering n
Facility/Owner Name Facility ID#(if applicable)
29276 Bethlehem Church Rd., Oakbor 28129 seams:59',75',ss', --1,T;_125';,14T=ag
n. n.
Physical Address,City,and Zip 21.REMARKS
Stanly 21858
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• rtitication:
(if well field,one lat/long is sufficient)
N W 7/27/21
S' ture o Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance
ivith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?]No copy of this record has been provided to the ivell owner.
jthis 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
S.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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24s. For AR Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: ry construction to the following:
(Le.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) 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.
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Form GW-1 North Carolina Department of Environment mid Nanaal Resources—Division of Water Resources Revised August 2013
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