GW1-2012-01112_Well Construction - GW1_20120429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.
Dwight L. Huneycutt FROWATER ZONESM TO DESCRIPTION
Wall Contractor Name '\ 195 n' 205 n' 30 gpm
®
4070-A ECE V n. n.
NC Well Contractor Certification Number q (] 202i 15.OUTER CASING for multi-eased wells OR LNER a llcable
Ll �7 FROM TO DIAMETER Tffi(RQVESS MATEItIAI.
Derry's Well Drilling, inc. AP © n 45 n 6 1/8 " SDR-21 I PVC
Company Name inloemation r 16.INNER CASING OR TUBING fiteotberwal closed-loop)
nWR Sion FROM TO DIAMETER TIUCIM'ESS MATERIAL
2.Well Construction Permit#: Y• 0 n• 160 n 4 In. SCH 40 PVC
List all applicable ivell permits(i.e.County,State,Variance,injection,are.) n. n. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT SIZE TMCXNnS MATERIAL.
OAgricultural ❑Municipal/Public 160 n' 1220 n 4 In. .020 SCH 40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) n n• In.
(H PJ $ PP Y) PP Y( � $1)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO NLITFRUL ENIPIACEAWNY METHOD to AMOUNT
Qltri ation 0 n• 3 n• Bent.Chips Gravity
NOR-Water Supply Well:
3 n' 35 n' BentOnit@ Pumped
QMonitoring QRccovery
Injection Well: 0 n• 220 n• Cement Gravity
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPIACEMENT?.WM0D
❑Aquifer Storage and Recovery ❑Salinity Barrier n. n.
❑Aquifer Test ❑Stotmwatcr Drainage
n. n.
❑Experimental Technology ❑Subsidenec Control
20.DRILLIlVG LOG attach additional sheets U necessa
❑Geothermal(Closed Loop) QTraccr FROM TO DESCRIPTION color,hardness,sollfrock in etc
❑Geothermal astir Conlin Retum QOther(explain under#21 Remarks 0 lt. 21 n Brown Dirt
n' n
a.Dare Well(s)completed: 12/30/20 21 225 Slate
Well IDN
So.Well Location:
Brent Harrington
Facility/Owner Name Facility ID#(if applicable)
n. Seams: 68 72',74', 112', 188', 195'=309
Old Ruby SC Rd, Morven 28110
Physical Address,City,and Zip 21.REMARKS
Anson
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/nduutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
N ,,y 1/26/21
Signature of enified Well Contractor V Date
6.Is(are)the well(s): OPermaneut or ❑Temporary By signing this form,I hereby car*that::the ivell(s)was(were)consmicted in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of this record has been provided to the well owner.
If this is a repair,fill out known well constmerion 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 walls ONLY with the saint construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (fr.) Zan. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if eli emni(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 18 (it,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) tab.For Iniection Wells ONLY: In addition to sending the fora 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: ry construction to the following:
(i.e,auger,rotary,cable,direct push,eta.)
Division of Water Resources,Undergroimnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
130.Yield(gpm) 30 Method ottest: 'Air
24c.For Water Supply. &Infection 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.
i
Forty OW-1 North Carolina Deparuuent of Environment and Natural Resources—Division of Water Resources Revised August 2013