GW1-2023-02671_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FR WATER ZONES
ROM TO DESCRIPTION
Well Contractor Name - 90 H. 100 ft 75 gpm
4070-A v ft ft
NC Well Contractor Certification Number 15.OUTER CASING for mWti cased wells OR LINER if a livable
' 1 1 2023 FROM TO DIAMETER THICIQVFSS MATERIAL.
Derry's Well Drilling, Inc. V o % 49 ft' 6 1/8 '- 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothennal closed-l000l
244076 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J ft. ft. in
List all applicable well permits(i.e.County,State,Variance,injection,eta)
ft ft is
3.Weli Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 f" 3 It Bent.Chips Gravity
Non-Water Supply Well: 3 ft. 20 R- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Weil: ft. fL
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier F21fL
To ntATERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control
NG LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness,soil/rack etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks 21 ft Brown Dirt&Rock
4.Date Well(s)Completed: 318/23 well ID# 105 n. Slate
ft5a.Well Location: t D.
Carlton Thompson ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable)
ft rt. Seams:52',55',68',71',79,79',
Hilltop Rd., Oakboro 28129 ft ft 85',90'=75gpm
Physical Address,City,and Zip 21.REAfARKS
Stanly 7913
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N `,i, � ! 4/5/23
Signature ofC fied Well Contractor Date
6.Is(are)the weil(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 IDNo 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#21 remark section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or iron-water supply wells ONLY ivith the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 105 (tI) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ali depilns#dijjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 10 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 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) 75 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 Environmcnt and Natural Resources—Division of Water Resources Revised August 2013
I