GW1-2023-01651_Well Construction - GW1_20230213

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES '
FROM TO I DESCRIPTION
Well Contractor Name A a a;J'j a vd 275 ft• 280 fr' I 9 gpm
4070 A FEB 2023 a ft. ft.
NC Well Contractor Certification Number U ' FROM
OUTER CASING for mu16-cased wells OR I INER if a Gcahle
J FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. lnt�'rrroc n• '' ' yy:•':Q t r� 0 ft- 83 ft 6 1/8 ! !1O SDR-21 PVC
ry g,
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
36H653 FROM TO DIAMETER THICKNESS MATERIAL
,
2.Well Construction Permit#: ft. ft. °
List all applicable well permits(<•e.County,State,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 ini
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
pMonitoring ❑Recove 3 ft 20 ft- Bentonit(3 Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft• ft
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❑Aquifer Test ❑Stormwater Drainage
ft ft i
❑Experimental Technology ❑Subsidence Control
20.DPJLLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soilfrock type,grain size,ac.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 12 ft. i; Red Clay
10/21/22 12 fr• 52 ft ` Brown Dirt
4.Date Well(s)Completed: Well ID# 52 ft. 75 ft. Brown Rock
5a.Well Location: 75 ft- 300 ft Slate
Brandon Mullis ft. ft.
Facility/Owner Name Facility II)#(if applicable)
Old Mill Rd., Locust 28097 � f ' Seams: 101', 116', 132', 149',170',216',
It. ft ', 227',275'=9gpm
Physical Address,City,and Zip 21.REMARKS °
Stanly 138,440
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) I,
N R, // 1112/22
Signature of-Certified Well Contractor 1 Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Bell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E No copy of this 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
repair under 921 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page`id provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also4ttach additional pages if necessary.
For multiple injection or non-water supply ivells ONLYiPith the same construction,you can
submit one form. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: 300 00 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdoerent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing:
31 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. (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 form within 30 days of completion of well
12.Well construction method: ry 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) 9 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfectiou type: Granular Amount- 1/2 lb. well construction to the county h6 th department of the county where
constructed.
Farm GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013