GW1-2023-01647_Well Construction - GW1_20230213

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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.WATERZONES,' 1 f
Y FROM TO I DESCRIPTIONI I
Well Contractor Name 179 ft 185 ft 7 gpm
4070-A �.a ks�' �L l¢V it- ft &
r_:
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells OR LINER if a ]icable
FROM TO DIAMETER h 'THICIGWM MATERIAL
Derry's Well Drilling, Inc. F t� ZQ2� 0 ft. 160 ft 161/8 1 : I SDR-21 I PVC
Company Name p�r pia 23v=,g Unit 16.'INNER CASING'OR TUBING(geothermal closed-loop)
3648�t5- ~ to' i��J � FROM TO DIAMETER THICKNESS ]MATERIAL
2.Well Construction Permit#: 0 ° ft ft 1°`
List all applicable well permits(t.a County,State,Variance,Injection,etc.)
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
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
FROM TO MATERIAL " EMPLACEMENT METHOD&AMOUNT
❑hT,i tion 0 n 3 ft Bent.Chips, Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 ft Bentonite F�umped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)i
FROM TO iMATEmAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. '
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacti additional sheets if uecessa
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION{(color,hardness,son/rock a sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 9 ft Red Clay
4.Date Well(s)Completed: 4/23/22 Well ID# 9 R• 27 ft Brown Dirt
27 ft 52 ft Brown Rock
5a.Well Location: 52 ft 265 ff I, Slate
Scott&Tammie Dennis ft ft
Facility/Owner Name Facility ID#(if applicable)
166653 Five Point Rd., Locust 28097 ft ft Seams:66',76,79',85% 112', 131',
rr rr 134-138% 179'=7gpm
Physical Address,City,and Zip 21.REb1ARKS ]:'
Stanly 35160
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient) /
N W 'r 6/10/22
Signature o ertified 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 I5A 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 0No copy ofthis record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and explain the nature of the
repair under#21 remarlrs 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 same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#different(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Resources,Information Processing Unit,
If water'level is above casing,use"+' 1617 Marl Service Center,Raleigh,NC 276994617
I I.Borehole diameter: 6 (m.) 24b.For Iniection 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 Marl Service Center'Raleigh,NC 276994636
13a.Yield(gpm) 7 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 Resources, Revised August 2013•
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