GW1-2021-05812_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Dwight L. Huneycutt Fa.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name l IIT'+1 222 fL 230 ft 100 gpm
4070-AREC
I"J 3� ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cased wells OR LINER if a licable
JUL0 2021 FROM TO DIAMETER TBIC[STIPSS 11L1TERIAI
Derry's Well Drilling, Inc. UL 6_
ft. 57 ft- 61/8 i SDR-21 I PVC
Company Narne r�rooeSS(DO N 16.INNER CASING OR TUBING othermal closed-loo
InfoTrn�tl�n r PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 274752 c),N�j SjeCol1 ft. fr. is
List all applicable well permits(Le.Counly,Slate,Variance.Injection,etc.)
fL It, In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. % in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' tt in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trri ation 0 fL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 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 lZ ft.
❑Aquifer Test ❑Stormwater Drainage
fr. lZ
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if
❑Geothermal(Closed Loop) ❑Tracer [45
ROM TO DESCRIPTION color,hardness.sof/mtk 'n size,etc
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL 11 fL Brown Dirt
4/1/21 1 ft- 45 ft. Brown Rock
4.Date Wells)Completed: Well TD# fL 245 ft. Slate
5a.Well Location: ft, ft.
Josh Ferguson ft. ft.
Facility/Owner Name Facility iD#(if applicable)
Griffin-Greene Blvd, Oakboro 28129 ft. I` Seams:68',75',97', 155',222'=100g
fr. If.
Physical Address,City,and Zip 21 REMARKS
Stanly 139444
County Parcel identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/lono is sufficient)
N W
5/4/21
Signature of'Certified Well Contractor Date
6.Is(are)the well(S): OPermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 15A AK74C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
If this is a repair,fill out knonm well construction information and explain the nature of the
repair under ill remarks section or on the back ofthis 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.
har multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL TNST UCTTONS
9.Total well depth below land surface' 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdiffereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 14 ({t) Division of Water Resources,information Processing Unit,
Ifwater level is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: Tn 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1�� Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form'within 30 days of completion of
/2 Ib•
13b.Disinfection type:
Granular Amount: 1 well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Nanual Resources—Division of Water Resources Revised August 2013
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