GW1-2022-03885_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For(mental 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 330 ft. 338 ft' I 5©jgpli`'":_"�r_�.�•,� ..�;..
4070-A ft. ft. v ;ii(
NC Well Contractor Certification Number 15.OUTER CASING for mulN-cased wells TO LINER if a licable
FROM TO DIAMETER TRICKINESS MATERIAL
Derry's Well Drilling, Inc. p ft. 46 ft- 6 1/8 in- SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
119947 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fit. R. in.
List all applicable trell permits(i.e.County,State, Variance,Injection,etc.)
ft. fit. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling/Coolin Supply) KIResidential Water Supply(single) ft. ft. in.
( g g PpY) PPY( g )
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 It. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
EMPLA
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM
ft. TO ft. MATERIAL CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soH/rock type,grain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 5 rt. Wet Fill Dirt
11/24/21 5 rt. 13 fit• Brown Dirt/Rock
4.Date Well(s)Completed: Well iD# 13 ft. 340 fit• Slate
5a.Well Location: ft. ft.
Summit Building Group LLC ft. ft.
Facility/Owner Name Facility iD#(if applicable)
fit. fit. Seams: 52',70',75',95', 150', 190',
Creekview St/ 108 Pine Ridge St, Locust 28097 fit. fit. 330'=50g
Physical Address,City,and Zip 21.REMARKS
Stanly 30802
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
Signature of Certified Well Contractor V Date
6.is(are)the well(s): (ZPermanent or ❑Temporary by.signing this farm,I hereby certify that the u•ell(s)tras(were)constructed in accordance
[rah 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 FIND copy ofthis record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under`21 remarks section or on the back ofthis farm. 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 wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 340 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple[cells list all depths ifili ferent(example-3 r@i 200'and 2 a@100') construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,information Processing Unit,
Ifwaierlevel 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 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,Linderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 50 Method of test: Air 24c.For Water Supply&injection Wells:
(gP ) 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 Resources Revised August 2013
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