GW1-2023-02708_Well Construction - GW1_20230411

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt la.R'ATERZONES i
FROM TO I DESCRIPTION
Well Contractor Name 150 ft. 156 ft I I 3 gpm
4070-A ft. ft. I I '
NC Well Contractor Certification Number ' ( 9 ?. ' 15.OUTER CASING for multi cased wells OR LINER if a lica6le
Y•'iz-* _.,'}L..,q.y ' FROM TO DIAMETER THIC[�IESS 5ATERIAL
Derry's Well Drilling, Inc. 0 ft. 148 ft. 61/8 iti SDR-21 PVC
Company Name APR — 20230 16.INNER CASING OR TUBING(geothermal closed-loop)
335556 FROM TO DIAMETER TMCK NESS MATERIAL
2.Well Construction Pi ft ft in
List all applicable well permits(t.e.County,State,Parlance,Ing lor�r�1cb,y ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agriculhrral ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 rr' 20 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,saillrack type,prain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 16 ft Brown Dirt
4.Date Well(s)Completed: 12/29/22 Well ID# 16 ft 33 ft Brown Rock
33 ft 345 ft. Slate
Sa.Well Location: It. ft
Naomi Hams,James Hams Jr LER
ft ft
Facility/Owner Name Facility ID#(if applicable)
Harris Rd., Oakboro 28129 ft rut- Seams:69',74',80',88',95', 150'=39pm
ft. ft
Physical Address,City,and Zip 21.REMARKS
Stanly 9787
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 ivell(s)was(were)constructed in accordance
Wilt 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1KINo copy ofthis record has been provided to'the mvell osvner.
If this is a repair,fill out known mvell construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: coustrction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply mvells ONLY with Cite same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 00 Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injection 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: 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) 3 Method of test: Air 24c.For Water Supply&Infection 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 Environment and Natural Resources—Division of Water Resources Revised August 2013