GW1--05174_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor infornwtion:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 55 ft. 60 ft 1 gpm
4070-A 132 f'- 138 ft 2 gpm
NC Well Contractor Certification Number Is.OUTER CASING(for multi-cased wells)OR LINER(if a kgble)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 46 ft. 61/8 ht SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
395090 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. 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
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft is
❑lndustriallCommercial ❑Residential Water Supply(shared) IS.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 ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R
❑Aquifer Test ❑Stormwater Drainage ft. ft.
—
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 23 ft. Brown Dirt
4.Date Well(s)Completed: 7/19/24 23 ft 32 ft Brown Rock
Well lD#
32 ft. 325 ft Slate
5a.Well Location: ft. ft.
Charles L. Richmond, III
ft ft Seams:55'=lg, 128', 132'=2g,215',248'
Facility/Owner Name Facility IDb(if applicable)
ft. ft.
Randall Rd., Wadesboro 28170 ft. ft. . , -.
•Physical Address,City,and Zip 21.REMARKS ~ �• s,
Anson 645900597002 AU( :. 0 2624-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: lf.'`,.:;'::•..' °; ' •-'`� ';; '.:r:
22.Certification:
(ifweD field,one lot/long is sufficient) CM%, k:::::.1
N D�� re/cat� 8/14/24
Signature of fled Well Contractor Datc
6.Is(are)the well(s): CdPernranent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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
9.Total well depth below land surface: 325 (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 2Q100') construction to the following:
10.Static water level below top of casing: 30 (fL) 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!election Welk 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(gpm) 3 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