GW1-2023-01433_Well Construction - GW1_20230208

I
WELL CONSTRUCTION RECORD Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES 6
Dwight L..Huneycutt FROM TO DESCRIPTIONI
Well Contractor Name o �y,ry A.n, f 189 ft' 194 ft. I 10 gpm
4070-A `E lm. ,a .s 0; a� :•." 205 ft 211 fi I 40 gpm .
NC Well Contactor Certification Number r (� 15.OUTER CASING for multi cased wells OR LINER if a licahle
FEBR �� (� V 23 FROM TO DGIMETERi TffiCIQVESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 165 ft 61/8 !'° SDR-21 PVC
Company Name Prt''C.5r.' `I''g Un.i 16.INNER CASING OR TUBING eothermal'closed-loo
363032 I viniBOG FROM TO DIAMETER . THICKNESS 11L1TERIAL
2.Well Construction Permit#: ft ft. �in:
List all applicable ivell permits fl.e.County,State,Variance,Injection,etc.)
ft ft .in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 1 SLOT SIZE THICIQVESS MATERIAL
ft ft. in. i.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon 0 fr. 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 ffaindi6ble
FROM TO 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 additionalsheets if recess
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soitfrack'type rain sire,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 a02rkid 0 ft 6 ft I Brown Sandy Topsoil
4.Date Well(s)Completed: 8/1/22 Well ID# 6 ft 15 ft Red Clay
15 ft 48 ft. Wet Clay&Cobbles
5a.Well Location: 48 ft 245 ft Blue Rock
Michael Powell ft ft
Facility/Owner Name Facility ID#(if applicable)
2154 Dickie Little Rd, Wadesboro 28170 ft ft Seams:75',90-96', 189-194'=10gpm,
ft. ft 205-211'=40gpm
Physical Address,City,and Zip 21.REMARKS
Anson 6761.00.05.2247
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N `il, 8/31/22
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form I hereby certify thal the ivells)ivas(were)constructed in accordance
ividi 15A NCAC 02C.0100 or 15A NCAC 0k.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [?]No copy of this record has been provided to the ivell owner.
If this Is a repair,fill out knoivn ivell construction information and explain the nature of the
repair under#21 remarks section or on the back ofdiis 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 non-ivater supply ivells ONLY ivith 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 ivells list all depths ijdii ferent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing:
20 (ft.) W Division of Water Resources;Information Processing Unit,
If water 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
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,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) 50 Method oftest• 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