GW1-2023-01649_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 1a,WATERZONES
FROM TO DESCRIPTION
Well Contractor Name '�ZZ ems,'Vl i;t 1Z 1 95 rt, 100 1" I 5 gpm
4070-A FEB 7 109 ft, 115 ft' 13 gpm
NC Well Contractor Certification Number 6 0 23 15.OUTER CASING for multi-cased wells OR LINER if a licahle
FROM TO DIAMETER i .TIHCKNESS MATERIAL
Derry's Well Drilling, Inc. In,�c ? ;i�� ?t c�,��s� Inc 0 rt 46 ft- 61/8 ;` in• SDR-21 PVC
Company Name r0 r'r�' ' 16.INNER CASING OR TUBING eothermal closed-loop)
355895 FROM To DLIMETER THICKNESS MATERIAL
2.Well Constriction Permit#; ft. ft. in
List all applicable well permits ri.e.Coun(,State,Variance,InjectioM 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) OResidential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 IL 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 iL Benton'ite, Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(ifauplicablel
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f, 11 ft. Red Clay
10/20/22 11 rc 22 ft Brown Dirt
4,Date Well(s)Completed: Well 1D#
22 rt 125 rt Slate
5a.Well Location: ft
Bill &Sarah Hazelwood fL &
Facility/Owner Name Facility 1D#(ifapplicable) ft. % Seams:54',70',88-90',95'=5gpm,
36561'Millingport Rd., New London 28127 (Lot 1)
rt. rt. J� 109'=13gpm
Physical Address,City,and Zip !
21.REMARKS
Stanly 19350 i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `l, T GLt,L,. 11/15/22
Signature ottertified Well Contractor 41 Date
6,Is(are)the well(s): RiPermanent or ❑Temporary By signing this form,I hereby certify thpl the well(s)uas(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 of this record has been provided to the well mvner.
If this is a repair,fill out known well construction information mid explain the nature of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well dcta17s:
You may use the back of this page to provide additional'well site details or well
8.Number of wells constructed: 1 construction details. Yod may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can i
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (ft.) 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 2@100) construction to the following:
ji
10.Static water level below top of casing: 25 (ft) Division of Water Resources,Information Processing Unit,
Ifumer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: i addition to sending the form to the address in
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:
(i.e.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 276994636
13a.Yield(gpm) 18 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 ofEnviromnent and Natural Resources—Division of Water Resources Revised August 2013