GW1--05175_Well Construction - GW1_20240830

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 55 ft. 58 ft 3gpm (72-75'=3gpm)
4070-A 112 ft. 115 ft. 19gpm (170-175'=25gpm)
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap beside)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft- 52 ft 61/8 in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
410136 FROM TO DIAMETER_ THICKNESS — MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft, ft. in.
❑Agricultural ElMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft BentonitE_ Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. R.
❑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,soil/rock type,train sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 14 ft•Red Clay
7/9/24 14 ft• 37 ft. Sandy Brown Dirt
4.Date Well(s)Completed: Well ID#
37 ft. 55 ft• White Granite
Si.Well Location: 55 ft- 185 ft' Blue Granite
Town of Wadesboro ft. ft.
Facility/Owner Name Facility ID#(if applicable) Seams:55-58'=3g,72-75'=3g, 108',
ft• ft' i 11 '-1.9g,116;124',170'=25g
2254 Lake Park Dr., Wadesboro 28170 ft. - r
Physical Address,City,and Zip 21.REMARKS A U G " G (614
Anson 647200387426
County Parcel Identification No.(PIN) s >:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Dastt 2,a
22 Certification:
(dwell field,one latflong is sufficient) _ �
N W Dl,Un- 8/4/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): I2Pennanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA 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 ONo 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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 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) 50 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