GW1--02831_Well Construction - GW1_20240506

• WELL CONSTRUCTION RECORD
For Intemnl Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 1 WATER ZONES DESCRIPTION'
Well Contractor Name 192 ft- 198 ft I 1 2 gpm
4070-A �.s (z r' rr--:, . ,'N ft ft I
1 i t"'�"r 1"=i � 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)'
NC Well Contractor Certification Number FROM TO DIAMETER ' THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAY 0 G 2a24 o ft 48 • ft 61/8 i it', SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
V+r..:"4 r i1 C'-•n4,.0:44' 1IJ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 331 Oz'� ' rtw :s 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
ft ft in...
❑Agricultural OMunicipal/Public
1❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage ,
ft. ft
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,plain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft 9 h Red Dirt
2/16/24 9 ft- 36 ft - Brown Rock
4.Date Well(s)Completed: Well ID#
36 ft 400 ft Slate
5a.Well Location: g• g,
Todd Springer ft ft Seams:72',91',99', 107', 123', 154',
Facility/Owner Name Facility ID#(if applicable)
ft ft i, , 192'=2g
Woodall Rd., Wadesboro 28170 ft ft.
Physical Address,City,and Zip 21.REMARKS • , '
Anson
County Parcel Identification No.(PIN)
i. ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /
N W D�.c.. 3/11/24
Signature of erufied Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certtty that,the well(s)was(Were)constructed in accordance
with 1SANCAC 02C.0100 or ISANCAC;02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZINo copy of this record has been provided to the well owner.
If this 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
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 1,
9.Total well depth below land surface: 4OO (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(3a 200'and 2Q100' construction to the following: li
10.Static water level below top of casing: 30 (f4) Division of Water Reso Irces,Information Processing Unit,
Ifwater 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
24a above, also submit a copy of tins'form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i'
(ie.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) 2 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 j department.of the county where •
constructed. 1
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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