GW1-2022-10025_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
'14.WATER ZONES
Dwight L. Huneycutt FROM TO I DESCRIPTION
Well Contractor Name . 'I � 230 ft' 237 ft 10 gpm
4070-A ' t E ""°E° VE ft.
NC Well Contractor Certification Number NOV, o 2 Z 15.OUTER CASING for multi cased wells OR LINER it a livable
FROM TO DIAMETER' I THICHIVESS •MATERIAL
Derry's Well Drilling, Inc. Y� „rti c,g,_ , 0 ft 55 ft 61/8 I; SDR-21 PVC
`' 16.INNER CASING OR TUBING eiiihermal closed-loop)
Company Name D+Fe Q1B0G
239882 FROM TO• DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. 1;h,
List all applicable ivell permits ri.e.County,State,Variance,Injection,etc.) it ft id
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER {SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑liTi ation p ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well: -
❑Monitoring ❑Recovery 3 ft 20 it Bentonitt3 Pumped
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier — It. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION enlar,hardness scufmck type,grain six,etc
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 & Red Dirt
4.Date Well(s)Completed: 12/18/21 Well EN 16
fr. 16 f• ! Brown Dirt
16 fr. 29 rr• i' Brown Rock
5a.Well Location: 29 n 245 ft. Slate
Jerry&Danielle Smith it ft
Facility/Owner Name Facility ID#(if applicable)
44267 Yadkin Brick Rd., New London 28127 ft ft Seams:70',n',85',so',99', 129',210',
ft ft. 230'=10gpm
Physical Address,City,and Zip 21.REMARKS-'
Stanly 11658
County Parcel Identification No.(PIN)
5b,Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification: l
(ifwell field,one lat/long is sufficient)
N W � 1/10/22
Signature of ertified Well Contractor Date
6.Is(are)the well(s): V7Permanent or ❑Temporary By signing this form,I hereby certify that lite 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 ❑No copy ofthis record has been provided to Cite,well owner.
If 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 of this 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.
For nmUiple 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: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3 t@200'and 2(Qa 100) construction to the following: {I
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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: I'n addition to sending the form to the address in
Rota 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i
(i.e.auger,rotary,cable,direct pushy,etc.) I'
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 10 Method of test: Air 24G For Water Supply&Injection Wells:
Also submit one copy of this forml-within 30 days ofcompletion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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