GW1-2022-03884_Well Construction - GW1_20220408

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
FROM TO DESCRIPTION
Well Contractor Name 227 fL 235 rL 7 gpm
4070-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR falicable
FROM T DIAMETER THIQ
MATERIAL
Derry's Well Drilling, Inc. 0 ft. 60 rt 6 1/8 in1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
334933 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
fit tt. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fit fL in. "--
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft is , 41 t
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMEN
❑irri ation 0 rt. rt.
Non-Water Supply Well: 3 Bent.Chips Gravity
❑Monitoring ❑Recovery 3 fit- 35 fit- BentonitePumped
Injection Well:
ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it necessa
❑Geothertnal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.barilness,soiUrotk tyM gritinsive,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 rL 7 ft Red Dirt
6/3/21 7 fL 31 ft. Brown Dirt
4.Date Well(s)Completed: Well il)# 31 fit- 47 ft. Brown Rock
5a.Well Location: 47 ft 300 fL Slate
Jeremy Almond ft. ft
Facility/Owner Name Facility ID#(ifapplicable) rt. ft. Seams: 73',76',90',95', 158',
29512 Burris-Burleson Rd, New London 28127 ft. rL 227'=7g
Physical Address,City.and Zip 21.REMARKS
Stanly 139992
Comity Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one IaUlong is sufficient) ��e�,J �(/
N w T�� LZ: ,�, r t 6/25/21
Signature of-ertitied Well Contractor Date
6.is(are)the well(s): [OPermanent or ❑Temporary By.stgning this furor, I hereby certify that the well(v)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 END copy of this record has been provided to the well owner.
lj7his is a repair,fill out known well construction information and explain the nature of the
repair under 121 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.
h'or multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUC PIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ii'docrent(example-3@200'and 2 tt l00') construction to the following:
10.Static water level below top of casing: 39 (f1) Division of Water Resources,information Processing Unit,
Ifsrater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rotary 24aabove, 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 Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection :
13a.]'field(gpm) 7 Method of test: Air 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 health department of the county where
constructed.
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Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aubmst 2013