GW1-2021-04496_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt �� 14.WATER ZONES
a115�.�OUTERICASING
TO DESCRIPTION
Well Contractor Name 62 ft' 3 gpm
4070-A � + e5� ft.NC Well Contractor Certification Number orl .'a for multi-cased wells OR LINER if a Gcable
Derry's Well Drilling, Inc. � �� �' FROM TO DIAMETER THICKNESS MATERIAL
ry g �� n�y 0 ft' 54 ft- 6 1/8 i° SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
123105 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: in.
List all applicable well permits(i.e.Cotunq,,State,Variance,Injection,etc.) ft ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
« in.
❑Agricultural ❑Municipal/ ublic rt•
P
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) t`' ft. 1° i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 35 rt• Bentonite Pumped
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIA tt. tt. I L EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
10.DRILLING LOG attach additional sheets if aecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/mck type,gnin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 7 ft. Red Clay
3/10/21 7 rt. 17 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
17 f` 26 « Brown Rock
59.Well Location:
26 rt• 400 f`• Slate
Edward Angel
Facility/Owner Name Facility ID#(if applicable)
Old Sandbar Rd., Oakboro 28129 Seams:75',88', 112',250',349',357'=39
ft. rt.
Physical Address,City,and Zip 21.REMARKS
Stanly 29933
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W D 4/7/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 211"ermanent or ❑Temporary Br,signing this farm,I hereby certify that u the ell(s)ryas(iverer constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Rell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy oflhis record has been provided to the well ottwer.
If this is a repair,fill out knoum well const action information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional wellidetails:
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 one forwt. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@a.100') construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Besotrces,Information Processing Unit,
If,rater 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cel1nter,Raleigh,NC 27699-1636
tgp ) 24c.For Water Supply&Injection 13a.Yield m 3 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water R 4somces Revised August 2013
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