GW1-2021-05840_Well Construction - GW1_20210709

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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:
John W. Huneycutt n14.
WATERZONES
y � FR FRo�1 To DEscRIPTtoN
,.
Well Contractor Name Z4 Vr�t 305 H• 310 ft' 1 gpm
2465-A J ,ocp§5xr9 446 ft. 450 n• I 2 gpm
r10� 15.OUTER CASING for multicased wells OR LINER if applicable)
NC Well Contractor Certification Number i�t 4t,(.r�O�w1��Q�-+ FltObt TO DIMtETFR TH]Cfff�'ESS MATERIAL
Derry's Well Drilling, Inc. \ V 0 ft' 146 n 6 1/8 " SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
21-146 FROM TO DIAMETER THICKNESS MATERIAL
2.Neil Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) H ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUL
ft. tL in.
OAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n ft. in.
❑lndustrial/Commereial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL E1fPLACEII>FNT METHOD&AAiOUNf
❑hri ation 0 ft. 3 H• Bent. Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 35 n Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
[]Aquifer Storage and Recovery ❑Salirrity Barrier FROM ft. TO n. MATERIAL I EMPLACEMENT n4ETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,wil/rock tyiie,gralti size,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 n' 21 ft' Brown Dirt
5/28/21 21 H 28 rt. Brown Rock
4.Date Weil(s)Completed: Well ID#
28 Tt 500 r` Blue Rock
5a.Well Location: ft. ft.
Donald Lee Shepard a. ft.
Facility/Owner Name Facility M#(if applicable)
rt. rt. Seams:79', 108', 169',210',256',305'=1g
3413 Belk Mill Rd, Wingate 28174 rt. ft
416',446'=2g
Physical Address,City,and Zip 21.REMARKS
Union 03-144-008A
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 6/15/21
Si rare of Certified Well ContractoE7Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I herebv certify that the ivell(s)ivas(were)constructed in accordance
with 15.4 NC4C 02C.0100 or 15.4 NCAC 02C.0200 Well Consinuction Standards and that a
7.Is this a repair to an erasting well: ❑Yes or RINo cogv ojthis record Has been provided to the well otrner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remorks section or on the back ojthis 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 constriction details. You may also attach additional pages if necessary.
For multiple injection or non-water stupply wells ONLY mith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this'form ivithin 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
If rroter 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,LJnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Iniection Wells:
Also submit one copy of this forrir 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. I
Fort GW-1 North Carolina Department of Enviroantent and Natural Resources-Division of Water RI somres ! Revised August 2013
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