GW1-2022-04339_Well Construction - GW1_20220411

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
g cu
y l:r P I y x^� FROM TO DESCRIPTION
Well Contractor Name 310 ft' 315 It' 1 gpm
4070-A A P a 11 202? fL fI
NC Well Contractor Certification Number 15.OUTER CAS ING for muaTwed UM BP icable
FROM T'gLA, DMR MATERIAL
Derry's Well Drilling, Inc. �p ,� } ,a;,l�, P.r>;i�l o ft s2 s va 1n SDR-21 PVC
Company Name `111 `I ` 16.INNER CASING OR TUBING othermal closed-loo
314816 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction Permit#: ft. ft. In.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nao'WaterSupplyWell: 0 ft' 3 1Bent.Chips Gravity
3 fL 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: Fw ft.
❑Aquifer Recharge ❑Groundwater Remediation FROM 19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft &
❑Experimental Technology ❑Subsidence Control
20.DRII.LIlVG LOG attach additional sheets if nceesea
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn sail/rockin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 & 33 ft Brown Dirt
4.Date We0(s)Completed: 9/13/21 Well ID# 33 fL 50 ft' Brown Rock
50 fit- 400 l" Slate
5a.Well Location: & ft.
Chris&Tiffany Ratliff ft. IL
Facility/Owner Name Facility ID#(if applicable)
Ansonville-Polkton Rd, Wadesboro 28170 ft. ` Seams: 90', 112', 129', 185-190',310'=1g
ft. ft.
Physical Address,City,and Zip
Zl.REMARKS
Anson
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifications
(if well field,one lat/long is sufficient) �L4J�l/ ll�
N w 9/30/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I 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
1.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out brown 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 INSTUCTIONS
9.Total well depth below land surface: 400 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli fereni(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing:
52 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this fort 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
13a.Yield(gpm) 1 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013