GW1-2021-05811_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycutt � � FROM TO DESCRIPTION
Well Contractor Name 30L 09 Zp 670 ft. 680 ft. 6 gpm
4070-A ft ft.
Unit
NC Well ses n
I Contractor Certification Number r,atiQ'{1 prog 15 OTERIAL
IUTER CASING for mal weUs OR 1 �f a licablblel
Derry's Well Drilling, Inc. Oti`��5e 0 ft55 ft
16 1/8 SDR-21 I PVC
Company Name I&INNER CASING OR TUBING othermal closed-too
115723 FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: ft. ft. in.
Lis[all applicable well permits(T e.County,State,Variance,Injection,etc.) ft. in.
ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SITE THICKNESS MATERIAL
ft. ft. In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft
❑industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
birri ation 0 ft' 3 rt. Bent.Chips Gravity
Non-Water Supply Well:
3 it 35 ft' Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL, EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft tL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it sexes
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hanln soil/rock tyM grain sime,etc
❑Geothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) 0 f• 16 ft Brown Dirt
5/11/21 16 ft. 24 ft. Brown Rock
4.Date Well(s)Completed: Well iD# 24 fL 590 f• Slate
5a.Well Location:
Terry B Haywood 590 c 660 f Gray Granite
660 685 Slate
Facility/Owner Name Facility TD#(if applicable)
ft. iL Seams:68',89', 134', 167',223',270',435',
8054 Whitley Rd, Norwood 28128 ft. fL
515',549',590',660',670'=6g
Physical Address,City.and Zip 21.REMARKS
Stanly 2006
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one Iat/long is sufficient)
N W Q 'd.G � 6/1/21
Signature ofCWitificd Well Contractor Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By,signing this form,I hereby certify that the weU(s)was(here)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis 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 r21 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
.submit one form SUBMITTAL INMTCTiONS
9.Total well depth below land surface: 685 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
Nor multiple wells list all depths 1f d�erent(example-3@200'and 2 a 100) construction to the following:
10.Static water level below top of casing 41 (ft.) D vision of Water Resources,information Processing Unit,
Ifrvaterlevel is abm=e casing,use^+- 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection 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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Vnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 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 he6lth department of the county where
constructed.
Form GW-i North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources i Revised August 2013
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