GW1-2022-03887_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.John W. Huneycutt FROM WATER I'
FROM TO DESCRIPTION
Well Contractor Name 86 ff 100 ff 6 gpm
2465-A 156 ft. 165 ft. 14 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL.
Derry's Well Drilling, Inc. 0 ft• 144 ft- 6 1/8 i" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
363507 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well perntirs rt.e.County,Slate,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TH n A RIAL
❑Agricultural ❑Municipal/Public ft. ft, in. I
r-' ^^
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft iO .�T =,
❑industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 fr. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'cable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fiL ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets J necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soft/rock tyM grain si e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 8 ft. Brown Dirt
9/24/21 8 fL 21 ft. Brown Rock
4.Date Wells)Completed: Well 1D# 21 f' 185 ft. Slate
5a.Well Location: ft. ft.
J Malcolm Harwood ft. ft.
Facility/Owner Name facility iD#(ifapplicable) ft. ft. Seams: 50',56',74',86'=6g, 100', 156'=14g
28865 Pole Running Rd, Mt. Pleasant 28124 ft. ft.
Physical Address,City,and Zip 21 REMARKS
Stanly 35679
County Parcel Identi fication No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one Iat/long is sufficient) /
N N, /� w• 10/18/21
Sign ol'Certitied Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this furor,l hereby certify that the well(s)was(were)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 ❑No copy ofthis record has been provided to the well owner.
lfthis is a repair,fill out kn nvn well conciruc•tion information and explain the nature of the
repair under"21 remarks section or on the back of 1his 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,
h'or multiple injection or non-water supply wells ONLY with the same construction,you can
submit rme form SUBMITTAL INST TMONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdierent(example-3@200'and 2@100`) construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,information Processing Unit,
lfwater level 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
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.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013