GW1-2023-01431_Well Construction - GW1_20230208

Il
I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 1144.MATERZONES"TO DESCRIPTION"
Well Contractor Name 150 ft 160 10 gpm
4070-A ft. ft.
f ;
NC Well Contractor Certification Number J Z023 15.OUTER CASING,for multi-cased wells OR LINER if a licable
F I-11 ! J ►! FROM To D.MET" THIMESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 177 ft 61/8 SDR-21 PVC
Company Name �FY ^
nr+� 16.INNER CASING ORTUBING(geothermal dosed-too "
380232 ��°s°� J� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: ft. ft. is
List aft applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL.
ft. ft In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 ft' Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: It. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a h'cable
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑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,soillrock a s' etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft: 8 ft. i Red Clay
4.Date Well(s)Completed: 9/24/22 Well ID# 8 f L 27 ft Black Dirt&Gravel
27 fr 67 ft. Junky Blue Granite
5a.Well Location:
67 ft 185 It. Blue Granite
Larry Kendale/Benny Phan/P&P Poultry
fG ft
Facility/Owner Name Facility ID#(if applicable)
ft Sea
3410 White Store Rd, Wadesboro 28170 ft. Seams:88',95', 117', 135', 150'=10gpm
ft. ft
Physical Address,City,and Zip 21.REMARKS
Anson 6464.00.22.0241
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient)
N W
10/11/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
13y signing this join;1 hereby certify that the wells)ivas(were)constructed in accordance
with 15A N({AC 02C.0100 or 15A NCACI02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well' ❑Yes or R]No copy of this record has been provided to the ivell owner.
If this is a repair,fill out knoivn 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
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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: If..within 30 days of completion of well
For multiple wells list all depths Y different(example-3@200'and 2@I00) construction to the following: i
10.Static water level below top of casing: 32 (110 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Ce{ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: in addition to sending the form to the address in
Rota 24a above, also submit a copy of this ftirm within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
Q.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: Air
24c.For Water Supply&Iniectionll Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib• 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