GW1--07596_Well Construction - GW1_20231121

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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.WATER ZONES - - . i=
9 Y FROM TO DESCRIPTION
Well Contractor Name 197 ft 205 ft I 3 gpm
4070-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if airlicable) - -
FROM TO DIAMETER , THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ' ft 44 ft 61/8 in. SDR-21 PVC
Company Name -16.INNER CASING OR TUBING(geothermal closed-loop)'- - -- - - -
397726-1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,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
❑Agricultural OMunicipal/Public to
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT-= :-- -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OIrrigation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply,Well:
OMonitoring ❑Recovery 3 ft• 20 . ft 'Bentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation -19.SAND/GRAVEL PACK(if applicable) - - -- --- - --- - --
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control • --20.DRILLING LOG(attach additional sheets if necessary)`- - _ ---- - --- - ---
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 21 S ft Brown Dirt
4.Date Well(s)Completed: 8/16/23 well ID# 21 4 500 4. Slate# 1 ft. ft. •
5a.Well Location: • ft. ' - ft. -
Charles Cline
Facility/Owner Name Facility LD#(if applicable)
ft ft Seams:55',68',93',197'= gg
ft. ft. .
107 Maple St., Locust 28097
ft. ft. f b _a•ij �—,7
Physical Address,City,and Zip .
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Stanly 2652 NOV 9 t 2023
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: _' �'�'",` �'E;:i
(if well field,one lat/long is sufficient) 1 v- ;
N W D r t :rtt- 9/2/23
Signature of�ll Contractor , Date
6.Is(are)the well(s): OPermaneut or OTemporary By signing this form,I hereby certt&that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 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.
If this is a repair,fill out known well construction information and explain the nature oldie
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: 500 (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 30 (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: 6 (in.) . 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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) '
Division of Water ResourceslUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) `3 ,_ Method of test: AI r
24c.For Water Supply&Injection Wells:
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Also submit one copy of this forin 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 OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013