GW1-2021-04498_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt +� 14AATERZTO DESCRIPTION
Well Contractor Name 0, ���� 180 ft 190 ft 40 gpm
4070-A PQ�� Q�o�,g `oo ft ft
NC Well Contractor Certification Number �' 15.OUTER CASING for multi-cased wells OR LINER if a linable
'�!1 FROM TO DIAMETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. � �p� o ft 45 ft' s 1/8 I° SDR-21 I PVC
9 Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)��~
317314 FROM To DLIMETER THICKNESS MATERIAL
2.Well Construction Permit It: ft. ft
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 I THICKNESS I MATERUII.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 ft Bentonite Pumped
Injection Well: f
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiltrack type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 7 ft Brown Dirt Rock
7 ft 185 ft Slate
4.Date Well 11/6/20 s)Completed: Well ID# ft ft
5a.Well Location: ft. ft.
Clayton Homes ft, ft
Facility/Owner Name Facility ID#(if applicable)
n ft Seams: 50',77', 180-190'=40g
Buster Rd., Oakboro 28129 ft. ft
Physical Address,City,and Zip 21.REMARKS
Stanly 29451
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 11/28/20
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)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 0No copy of this record has been provided to,the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under 921 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
S.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: 185 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft) 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 Iniection Wells ONLY: In 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
In Wells:
13a.Yield(gpm) 40 Method of test: Air 24c.For Water Supply&Wecti
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 h"ealth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013