GW1-2023-02705_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 14.WATERZONES
g Y FROM TO DESCRIPTION I
Well Contractor Name 117 ft. 120 ft. I 2 9Pm
4070-A 149 ft. 155 ft. 3 gpm
NC Well Contractor Certification Number 5'. i f 15.OUTER CASING for multi cd wells TO LINER if a fixable
.� > �i ,.�,' `�'""? ' FROM TO DIAMETER THICIQVESSI MATERIAL
Derry's Well Drilling, Inc. "y 0 ft- 74 ft 6 1/8 SDR 21 I PVC
Company Name APR 1 s2023 16.INNER CASING OR TUBING(geothermal closed-luo
377411 FROM TO DIAMETER THICKNESS MATERIAL
2.We11ConstructionPermit#: __ •:_._ • ._. . .. ft. ft. in.
List all applicable well permits(i.e.County,Still;7faridnce Injection ejc:)""`� '''``
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) ElResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 20 ft. Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
[]Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gmin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 24 ft. Red Dirt
3/2/23 24 ft 33 ft. Brown Dirt
4.bate Well(s)Completed: Well EN
33 ft- 61 ft. Brown Rock&Quartz
5a.Well Location: 61 fL 185 ft Slate
Ronald&Debra Coble ft.
Facility/Owner Name Facility ID#(if applicable) R fr.
Seams:79',84',95', 108, 117'—
—2gpm,
28147 Pole Running Rd, Mt. Pleasant 28124 ft. ft 149'=3gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 5544
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N W 3/21/23
Signature of Certified Well Contractor Date
6.1s(are)the well(s): I211'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthus record has been provided to the well owner.
If thus is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofrhis 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 non-water supply wells ONLY with lire same construction,you can
submit one form. SUB1yIITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (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:
10.Static water level below top of casing: 30 (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 Infection 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. 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) 5 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 It). well construction to the county health department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources=Division of Water Resources Revised August 2013