GW1-2023-02706_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
1.Well Contractor Information:
Dwight L. Huneycutt FROM
ER ZONES
ROM TO DESCRIPTION
Well Contractor Name " _ 232 if 240 if 30 gpm
4070-A I=„,K yy " a .sa; 1; & fr.
NC Well Contractor Certification Number APR R Y 12023
15.OUTER CASING for multi-cased wells OR LINER 'fa lieabI
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o fr. 45 ft 61/8 SDR-21 PVC
Company Name a17w� � 16.INNER CASING OR TUBING(geothermal closed-loop)
369524 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(i.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 in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATFRLALL EMPLACEMENT METHOD&MiOUNT
❑Irri ation 0 fr. 3 ft Bent.Chips Gravity
Nan-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 a• Bentonite Pumped
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERLIL EMPLACEMENT AD TROD
rr. ft.
❑Aquifer Test ❑Stormwater Drainage ft ft-
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type rain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0. ft. 22 ft Brown Dirt Rock
4.Date Well 12/28/22 22 ft 265 ft Slates)Completed: Well ID# ft ft.
5a.Well Location: ft. &
Danny&Laura Bigford fr• It.
Facility/Owner Name Facility ID#(ifapplicable)
12501 Philadelphia Church Rd., Stanfield 28163 ft• Seams:55',72',s6', 111',176',224',
p ft fr. 232'=30gpm
Physical Address,City,and Zip
21.REMARKS
Stanly 17683
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 1/15/23
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(ivere)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 [Z]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out knomi well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 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 b jection or non-water supply wells ONLY with lite same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdii ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing- 18 (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 iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 27699-16M
13a.Yield(gpm) 30 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb• well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013