GW1-2021-05834_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information: -V%
Dwight L. Huneycutt � FR WATER ZONES i
FROM TO DESCRIPTION i
Well Contractor Name O 235 f` 240 f` 3 gpm
4070-A �`)L Veit tt ft. i
NC Well Contractor Certification Number ©S,e�S`n9 15.OUTER CASING for multi cased wells OR LINER if a lieable
�C FROM TO DIAMETER THICKNESS 11fATERIAL
Derry's Well Drilling, Inc.%,rl �r"3n�NRSe��'Or 0 f` 55 f` 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-too
21-17 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. TO
is
List all applicable well permits fl e.County,State,f'ariance,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) ElResidential Water Supply(single) ft. ft. in,
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f` 35 ft- Bentonite Pumped
Injection Wen: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if oecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hartness,soilfrock type,grain size,do
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 f` 13 ft Red Clay
4/21/21 13 f` 29 f`• Brown Dirt
4.Date Well(s)Completed: Well LD# 29 ft 285 f` Slate
5a.Well Location: ft. ft
Dan Cole tL ft.
Facility/Owner Name Facility lD#(ifapplicable) ft rL
6208 Olive Branch Rd.,Wingate 28174(Griffin Estates Lt13) Seams:60',88',95', 111', 187',235'=3g
rt. rt
Physical Address,City_and Zip 21.REMARKS
Union 021990052
County Parcel Identification No.(Pith
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field.one latAong is sufficient)
N W 5/10/21
Signature er tied Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this farm, I hereby certify thai the well(y)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 0No 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 Y21 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit cme form. SUBMITTAL iNSTUCI'LONS
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 38 (ft,) Division of Water Resources,information Processing Unit,
Ifwater level&above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen'ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method oftest: 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: 112 lb. well construction to the county health department of the county where
constructed. i
Farm GW-I North Carolina Department of Environment and Natural Resource—Division of Water Resources Revised August 2013
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