GW1-2021-05854_Well Construction - GW1_20210709

f
s
WELL CONSTRUCTION RECORD For in[emal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt ®� ��� 14.WATER ZONES
g Y FROM TO DESCRIPTION
Well Contractor Name 150 IL 160 ft 10 gpm
4070-A JUL 4 `� 2021 378 ft- 385 IL20 gpm
NC Well Contractor Certification Number U nit I5.OUTER CASTNC for multi cased wells OR LINER if a livable
prroCeSS1110 FROM TO DIAMETER' THI WSS AL4TERIAL
Derry's Well Drilling, Ingnfatrr3t �gP Pion 0 ft- 44 fL 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#:
Parcel # 1033 (Well #2) FROM ft. TO ft. DIAMETER 1n• THICKNESS I MATERIAL
List all applicable well pernrrts(t.e.County,State,Variance,Injection,etc.)
ft. I ft. !1n.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SL.OTSIZE THICKNESS MATERIAL
ft. ft in.
❑+Agricultural ❑Municipal/Public
[]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 LL 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 fr 35 ft Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SANDIGRAVELPACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft.To NIATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
ft. tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atteeh additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,soft/rock in save,eta
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 12 ft. Red Clay
a.Date wens)Completed: 3/15/21 Well 1D#2 12 fL 27 ft Brown Dirt
27 fL 500 ft• Slate
Sa.Wt41 Location: tt. ft
Jerry Hudson tL &
Facility/OtvnerName Facility iD#(ifapplicable) It. fL Seams:66',90', 114', 150'=10gpm,223',
2623 Silk Hope Rd, Siler City 27344 fL tL
378'=20gpm,433',455'
Physical Address,City,and Zip 21.REMARKS
Chatham 1033
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one Iattlong is sufficient) /
N w 4/1/21
Signature ofCatied Well Contractor iv Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary py,signing this form, l hereby certify that the wel/(s)was(ivere)constructed in accordance
with 15A IVCAC 02C.0100 or 15A NC AC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this recori has been provided to the well owner.
If this is a repair,f 11 out known well construction information and explain the nature of the
repair under ii21 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Por multiple injection or non-water supply wells ONLY with the.same construction,you can
submit one form SITBMLTTAL INSTUCTiONS
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Haar multiple wells list all depths ifdi_(jerew(example-3 a200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 30 (ff•) Division of Water Resources,information Proccssing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For injection Welts 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.field(gpm) 30 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: Amount: 1/2 It)
Granular 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