GW1-2023-02689_Well Construction - GW1_20230411

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: '
Dwight L. Huneycutt 14.WATER-ZONES i•: t
FROM TO I DESCRIPTION
Well Contractor Name 250 ft 260 ft. I j 12 gpm
4070-A ft. fi.
NC Well Contractor Certification Number n° u A s-v>' 15.OUTER CASING for dti-casedwells ORINfaGcable
TFROM T DIAMETER S
MATERIAL
Derry's Well Drilling, Inc. APR 1 t 2023 0 fr 45 ft 61/8 i°. 1 , SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-lao
'f7i'�� y,_ 1 t FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 118810 ,,t;'i ft. ft. in
List all applicable well permits(i.e.Coun(K State,Variance,Injection,etc.) it. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUL
❑Agricultural ❑Municipal/Public ft ft in.
❑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
DIrrigation 0 fr. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft• 20 fr Bentoniie Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation r4fl.
RAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier To 11L1TERIAL EMPLACEMENT METHOD
ft
❑Aquifer Test ❑Stormwater Drainage fr.
❑Experimental Technology OSubsidence Control
NG LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness,soil/rack a size.eta
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 4 ft. Red Clay
1/20/23 11 ft• Brown Dirt
4.Date Well(s)Completed: Well ID# 300 ft Slate
5a.Well Location: ft
Phillip Austin f. fr. ,
,
Seams:50%54',69,75, 130,217
` Facility/Owner Name Facility ID#(if applicable)16726 Silver Rd., Oakboro 28129 ft & 250'=12gpmft. ft.
Physical Address,City,and Gip 21.REMARKS
Stanly 4292
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 W D � 7/20/22
Signature otCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EJNo copy ofthis 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 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft•) Division of Water Resources,Information Processing Unit,
Ifivater 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
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 27699-1636
13a.Yield(gpm) 12 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form wwtthin 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 of Environment and Natural Resources—Division of Water Res I our I S Revised August 2013
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