GW1--05006_Well Construction - GW1_20230807

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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 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name —+.3--r} 250 ft. 260 ft. 8gpm
4070-A ti b:.+..•i.; 4I a�'r",
ft: ft
NC Well Contractor Certification Number A U G 0 7 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
2023FROM TO DIAMETER I ! THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 45 ft• 61/8 in. SDR-21 PVC
Company Name ( .. r.'t.^l i'r;-*;:g+J:'r�fir..
p y lnt",;,.,;,,, 16.R INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 118682 D+1 �?I „1(„� FROM ft. TO DIAMETER ft. in. THICKNESS MATERIAL
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
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. rt. in.
❑Industrial/Cotnmercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 9 ft. Brown Dirt
4.Date Well(s)Completed: 11/18/22 Slate
Well ID# 9 tt• 285 ft Slate
ft. ft.
5a.Well Location: ft. ft.
J Malcolm Harwood ft. fr.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Seams:52',55',61',66', 121', 168',210',
36654A Finger Rd., Mt. Pleasant 28124
Physical Address,City,and Zip 217,250—8gpm
21.REMARKS
Stanly 38032
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 W P�� 11/30/22
Signature of citified Well Contractor Date
6.Is(are)the well(s): I71Perntanent or DTemporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1SA 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 ENo 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 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: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@I00' construction to the following:
10.Static water level below top of casing: 36 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Marl 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
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) 8 . 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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