GW1-2022-04338_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
t® '� FROM TO DESCRIPTION
Well Contractor Name o ' ' ` " 140 fL 145 ft. 15
gpm
2465-A rL r� gpm
APR 11 ?M 170 175 5
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a IicaMe
FROM TO DIAMETEW THICIdVE55 MATERIAL,
Derry's Well Drilling, Inc. 0 ft. 68 fL 16118 in SDR-21 PVC
Company Name " ? t� 1~ ''I''r` 'v 16.INNER CASING OR TUBING eothermal closed-loop)
05292101 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. �in.
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 THICKNESS MarERUL
❑Agricultural ❑MunicipaUPublic fL ft. in.
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) ft ft.
M g/ g PPP) PPP( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) M GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Ifni ation 0 n 3 rL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rL 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation FROM 19.SAND/GRAVEL PACK 1'a licablc
'. EMPLA
❑Aquifer Storage and Recovery ❑Salinity Barrier ft TO fL MATERIAL CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness soillmck 'e ttc
❑Geothermal(Heating/Cooling Return) ❑other(explain under#21 Remarks 0 ft. 8 fL Red Dirt
8 fL 35 ft. Brown Dirt&Rock
4.Date Well(s)Completed: $�19�21 Well ID#
35 fL 205 fr. Blue Rock
5a.Well Location: tL ft.
Martin Evans ,t. ft
Facility/Owner Name Facility ID#(if applicable)
rL R Seams: 128', 140-145'=15g, 170'=5g
Randall Rd, Wadesboro 28170 ft. ft.
Physical Address,laity,and Zip 21 REMARKS
Anson 6540-00-92-6417
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 9� w• 8/16/21
Si tore of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)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 ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out(mown well construction information and explain the nature of the
repair under#21 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 INSTUCI'IONS
9.Total well depth below land surface: 205 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#'different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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
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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
�2 lb.13b.Disinfection type:
Granular Amount: 1 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