GW1-2022-10026_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information.
Dwight L. Huneycutt, 14.WATER ZONES 6
FROM TO DESCRIPTION
Well Contractor Name - Ea V F!U 217 ft 220 ft 39pm
4070-A Al (� f• ft G
NC Well Contractor Certification Number NOV V 0 7 2022 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. i, �r;<��, Una o f4 46 ft 6 vs t is SDR-21 PVC
Company Name D%AIOJ;30G 16.INNER CASING OR TUBING eotbermal closed-loo
236587 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well permits Cie.Cowny,State,Variance,Injection,etc.)
ft. ft is
I'
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATFRL&L
❑Agricultural ❑Municipal/Public ft % in.
❑Geothermal(Heating/Cooling Supply) Mesidential.Water Supply(single) fG ft irr
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ;,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft- Bentonite Pumped
Injection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
20.DRILLING LOG attach additional sheets if necessa
[:)Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,miUrock sire,eta
[:]Geothermaleating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 12 ft. Brown Dirt
6/30/22 12 ft 17 f< I' Brown Rock
4.Date Well(s)Completed: Well EM 17 rt. 345 ff i! Slate
Sa.Well Location: ft ft
Mark Allen
ft. ft
Facility/Owner Name Facility ID#(if applicable)
40284 Mountain Creek Rd., New London ft ft Seams`.75',92-95',173', 195',217'=3gpm
ft ft.
Physical Address,City,and Zip 21.RE6fARK5'
Stanly 4452
County Parcel identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) 11
7/18/22
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): '1 Permanent or ❑Temporary By s !'
signing this form, hereby cert�that die wells)was(were)constructed in accordance
with 15A NCAC 01C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the i
repair under#11 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construcdon,you can
SUBMITTAL INSTUCTIONS
submit one form. j
9.Total well depth below land surface: 345 ({t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing: 48 ({t•) Division of Water Resources,Information Processing Unit,
Ifivater 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 24a above, also submit a copy of tlis,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: 163.6 Mail Service Center,Raleigh,NC 27699-1636
11
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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