GW1-2021-01780_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 6I6
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FRO ATER Z ONES DESCRIPTION;
Well Contractor Name (�a O�� 136 f` 138 ft' p 29pm
4070-A 9�, \�w 142 ft 148 ft I 3 gpm
NC Well Contractor Certification Number `'� e55 15.OUTER CASING for multi cased wells OR LINER if a licable
P BOG , O� FROM TO DIAMETERI THICKNESS MATERIAL
Derry's Well Drilling, Inc. oQ g� o rL 5o tt s 1/s 1° SDR-21 PVC
Company Name fi O 16.INNER CASING OR TUBING(geothermal closed-loo
2020010 �O` FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. ft. �i°•
List all applicable well permits(i.e.Couno,,State,Variance,Injection,etc) ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single) ft ft. in. j
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 20 ft- Bentonite Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. I ft. I '
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock in A etc.
❑Geothermal(Heating/CoolingRealm ❑Other(explain under#21 Remarks 0 ft. 7 ft' Red Dirt
6/4/20 7 ft
16 ft• Brown Dirt Rock
4.Date Well(s)Completed: Well ID#
16 ft• 245 ft Slate
5a.Well Location: ft. tt.
James Freeman ft. ft.
Facility/Owner Name Facility ID#(if applicable)
721 Dennis Rd. ft. ft. Seams: 110', 130-133', 136'=138'=29,
ft. fL I142-148'=3g
Physical Address,City,and Zip 21.REMARKS
Montgomery 6589-15-64-5558
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 6/30/20
Signature o Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the svell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Hell Conslrvuction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy ofthis record has been provided to the umll owner.
Ifthis is a repair,fill out knonn well construction information and explain the nahere ofthe
repair under#21 remarks section or on the back ofthis farm. 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 mithiple injection or now-water srupply wells ONLY with the same construction,yore can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 245 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-d a@200'and 2�ia 100) construction to the following:
10.Static water level below top of casing: 28 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter- 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary construction to the following:
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
(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) 5 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 health4cpartrnent of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources I Revised August 2013
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