GW1-2021-05813_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 14.WATER zoNEs
FROM TO DESCRIPTION
Well Contractor Name 219 ft. 225 ft t 12 gpm
4070-A JIJ� 0 9 2021 ft. fL . ,
NC Well Contractor Certification Number Unit 15.OUTER CASiNTG for malti cased wells OR LINER if:a'licable
Pr )
FROM TO DIAMETER THICKNE S MATERIAL
Derry's Well Drilling, Inc. Inforrr,3t On ��cYion 0 ft' 52 ft.
61/8 ! SDR-21 PVC
Company Name 16.INNER CASING ORTUBING(geothermal closed-loop)
306483 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable well permits ri.e.County,State,Variance,Injection,etc.) 2 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 in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 tL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 tr 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.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if Dec
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardam sciVrock rain sin,etc
❑Geothermal Heating/Cooling Retum) ❑Other(explain under#21 Remarks} 0 ft 7 Red Clay
3/31/21 7 fl. 22 ft. Brown Dirt
4.Date Well(s)Completed: Well il)#
22 ft- 40 ft Brown Rock
5a.well Location: 40 ft• 265 ft• Slate
Randy Huneycutt ft. ft.
Facility/Owner Name Facility iD#(if applicable)
rL rL Seams:59',75', 105',219'=12g
28337 Harwood Rd, New London 28163 ft. ft.
Physical Address,City,and Zip 21•REMARKS
Stanly 10491
County Parcel identification No.(PIIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field one lattlong is sufficient) 1/
N w � � j'I .l 4/13/21
Signature of.rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed m accordance
with 15A NCAC 02C.0100 or 15A N(:AC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or KIND copy of this record has been provided to the well owner.
If this iv 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 roe farm. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 265 (ft.) 24a. For All wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 22 (ft.) Division of Water Resources,information Processing Unit,
Ifwaterlevel is abm=e casing,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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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 this form`within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.anger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 12 Method of test: Air 24a 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 Ib well construction to the county health department of the county where
constructed. 4
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Form OW-i North Carolina Department of Environment and Natural Resources—Division of Water Resources I Revised August 2013