GW1-2023-01432_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
x
Y FROM TO DESCRIPTION'
Well Contractor Name � s, 216 It 220 ft. 1 8 gpm
4070-A FRO �.io ' � ti ft it
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a livable
FEBJ 8 2023 FROM TO DIAMETERI 1 THICKNESS MATERIAL
Derry's Well Drilling,Inc. 0 ft 77 ft- 161/8 lia SDR-21 I PVC
Company Name `nf0-r'r7'4oUa-•-n Pricm,!i"j +Pi 16.INNER CASING ORTUBING eothermalclosed-loo
372469 .�lC31i30v FROM TO DMETER , THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft DU METER
in.
List all applicable well permits(i.e.County,State,Variance,Injection,e1c.)
ft. ft.
3.Well Use(check well use): 17.SCREEN
-Water Supply Weil•_ FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft it in
❑Geothermal(Heating/Cooling Supply) OResidential Watc�Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERML, EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation '19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
�
❑Experimental Technology ❑Subsidence Control ft. ft
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness,sail] ck a rain sue,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 ft 16 ft Cobbles&Loose Sandy Dirt
4.Date well(s)Completed: 10/17/22 Well EN 16 ft 30 ft j; Cobbles&Yellow Clay
30 ft- 46 ft Brown Clay
5a,well Location:
46 ft 285 ft Blue Granite
Thomas Adams/Carolina Cust.Dream Hms ft &
Facility/Owner Name Facility ID#(ifapplicable) ft ft Seams:90', 109�, 133', 154',179�,
Ingram Mountain Ind., Lilesville 28091 ft ft
Physical Address,City,and zip 216,_'$gpm
Anson 7415.00.38.6832 21.REM1fARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degreeshninutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient) /L / 1����
10/31/22
N W
Signature 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 0No copy ofthis record has been provided to the ivell 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 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: 1 construction details. You may also attach additional pages if necessary_
For multiple injection or ton-water supply wells ONLY with the same cons-&ucdon,you can
submit one form. I SUBMITTAL INSTUCTIONS
i
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muftipfe wells list all depths tj'different(example-3@200'and 2@100) construction to the following: I;
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 27699.161;
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: It addition to sending the form to the address in_
Rota 24a above, also submit a copy of this;form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(Le.auger,rotary,cable,direct push,etd.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 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-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013