GW1--05138_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
9 Y FROM TO DESCRIPTION
Well Contractor Name 83 ft 85 ft 2 gpm
4070-A 198 ft 200 ft 58 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 45 ft. 6 1/8 in- SDR-21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
392322 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fa ft. M.
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 ❑Municipal/Public tt, ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) tL rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS. ROUT
FROMG 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. R.
❑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 ❑Stormwater Drainageft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,seiVrock type,grain sine,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 16 ft- Brown Dirt&Rock
3/7/24 16 fr. 200 fl. Slate
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft• ft.
Cameron Whitley ft.
ft. Seams:68',71',79',83'=2g,94',99',
Facility/Owner Name Facility IDk(if applicable)
10992 Hazard Rd., Oakboro 28129 ft. ft. 114', 138', 189', 193-196', 198'=58g
ft. ft. '--
Physical Address,City,and Zip 21.REMARKS l ‘,ti. `. ,..,. ' :r t -
Stanly 30435 AUG
J � lLZ4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification: li-,`'J:::' - '-- ' •.-? IJs
(if well field,one lat/long is sufficient) '
�w -z. u
- a.
N 4/1/24
Signature of'Certified Well Contractor Date
6.Is(are)the well(s): !Permanent or ❑Temporary fly signing this form I hereby certify that the well(s)was(were)constructed in accordance
with/5A NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or RiNo 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.2l 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: 200 (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®/00) construction to the following:
10.Static water level below top of casing: 30 (ft,) Division of Water Resources,information Processing Unit,
If water level is above casing,use"•" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 m 60 Method of test Air 24c.For Water Supply&Injection Wells:
(gpm) 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