GW1-2021-04502_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: '
DWIDwight L. Huneycutt 14.WATER ZONES
g ®� FROM TO DESCRIPTION
Well Contractor Name 171 It. 176 ft. 10 gpm
4070-A
NC Well Contractor Certification Number V g���J 15.OUTER CASING for multi�ased Hells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. a y Qor�`oo 0 ft 76 ft• 61/8 , in SDR-21 PVC
Company Name O ��� 16.INNER CASING OR TUBING(geothermal closed400
117224 O�Q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fr. tt. in
List all applicable well pertnits(i.e.County,State,Itarionce,/njectiO� efc.
ft. ft. in.
3.Well Use(check well use): ��x 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIC ESS MATERIAL
ft. ft,❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fr. 3 fr. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 35 ft• Bentonife Pumped
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 6 ft. 1 Wet Red Clay
2/9/21 6 rt. 23 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
23 fr 62 ft• Brown Rock
5a.Well Location:
Marsha Pope62 ft• 185 ft. Slate
Facility/Owner Name Facility ID#(if applicable)
«. ft. Seams:79-86',95', 171'=10g
St. Johns Dr., Stanfield 28163 ft. ft.
Physical Address,City,and Zip 2L REMARKS
Stanly 30823
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 3/1/21
Signature o Certified Well Contractor V Date
6.Is(are)the well(S): ©Permanent or ❑Temporary Bn signing this form,I hereby certify that the vell(s)was(were)constructed in accordance
With 15A 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 ElNo cop)of this record has been provided to the ve/l owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or•on the back of this form. 23.Site diagram or additional wellAetails:
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 mtdliple injection or non-water supp(v 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 ifdierent(example-3@200'and 2@I00� construction to the following:
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10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
If,vater 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: 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CiInter,Raleigh,NC 27699-1636
24c.For Water Supply&InjectionlW.ells:
13a.Yield(gpm) 1 Method of test: Air 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 health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R soivices Revised August 2013