GW1--02829_Well Construction - GW1_20240506

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 14.WATER ZONES l t
9 Y FROM TO DESCRIPTION
Well Contractor Name 332 ft, 339 ft• I 3 gpm
4070-A ft. ft. I I
NC Well Contractor Certification Number F s K""'r a, ,,.,.., 15.OUTER CASING.(for multi-cased wells)OR LINER(if ap`licable)
1.-� "' ` >;'„y FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. .p o ft- 58 ft- 61/8 !' SDR-21 PVC
Company Name MAY V (i 2024 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: lrx41rmV:..1 7r_„ ft. ft.. in.
List all applicable well permits(i.e.County,State,Variance,Injectiotr,eJc: „3 '�''�{;cW:r E
v�1' L7ij 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. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft• Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ` ft20 ' ft• Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge 0 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 0 Subsidence Control 20,DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 22 ft. Brown Dirt
3/11/24 22 ft- 28 ft. i. Brown Rock
4-Date Well(s)Completed: Well ID#
28 ft, 365 ft, Slate
5a.Well Location: ft. ft. ;
109 Farm
ft. ft. Seams:71',95, 135, 187,214,256,
Facility/Owner Name , Facility ID#(if applicable) ft. ft. 11277',294', 317',332'=3g.
Plank Rd, Wadesboro 28170 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Anson
County Parcel Identification No.(PIN) i
i.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /
N W
Du76 L. � - 4/11/24
Signature of Certified Well Contractor i' Date
6.Is(are)the well(s): I27Permanent or ❑Temporary By signing this form,I hereby cent&that the well(s)was(were)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 ElNo 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 1
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
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 the same construction,you can i'
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if deerent(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,
If water 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
Rotary 24a above, also submit a copy off 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,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: i g
13a.Yield(gpm) 3 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 Rest urces Revised August 2013