GW1-2021-04530_Well Construction - GW1_20210429

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or i nrltiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FR WATER ZONES
ROM TO DESCRIPTION
WellContmctorNinre 235 n 240 n 1 gpm
4070-A 2021 D. rt.
NC Well Contractor Certification Nwuber n p R 2 9 15.OUTER CASING for tnulti-cased we Its) LAVER f e Dcnble
H TO DL"ETER, TEIICI�'ES5 MATERIAL
Derry's Well Drilling, Inc. GOess'" o ft- !56 m s 1/8 SDR-21 PVC
Company Name ,fit;d( ``�W R S 16.INNER CASING OR TUBING eothermat closed-loop)
2O^624 D FROM TO DIAMETER TIHCKN'ES5 IAL.MATER
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft In
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER (SLOT SIZE I THICKNESS LNIATERUL
R. ft. in.
❑Agricultural ❑MunicipaMblic
ft.
❑Geothermal(Heating/CoolingSupply) ®Residential Water Supply(single) n• in.
❑hrdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL'. EMPLACEMENT METHOD AMOUNT
❑Irri ation 0 f• 3 R• Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 R Bentonite Pumped
❑Monitoring ❑Recov
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEII>ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt. ft.
❑Aquifer Test ❑Stortwater Drainage tt
[]Experimental Technology [3 Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer F
ROMTO DESCRIPTION color,hardness,soNtroek a le size etc.
❑Geothermal(Heating/CoolingReturn Mother(explain under#21 Remarks 18 n• Brown Dirt
4.Date Wel(s)Completed- 1/1 a/21 Well ID# 37 �. Brown Rock
425 Slate
Sa.Well Location: • n•
Austin Hills LLC rt. R.
i
Facility/Owner Nano Facility ID#(if applicable)
2331 Louanne Dr., Wingate 28173 f. n. Seisms: 61', 111', 178',235'=1g
Physical Address,City,and Zip 21.REMARKS
Union 02-199-058
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one latAong is sufficient)
N W D�,L 1/25/21
Signature o ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that:tire wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this retard has been provided to the well owner.
1f this is a repair,fill out known well consrniction information and explain the nature of the
repair tinder#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
$.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mthiple 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: 425 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdtiple wells list all depths ifdii different(example-3@200'and 2@1009 Construction to the following:
10.Static water level below top of casing:
24 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above casing,use"+" 1617 Mail Service Cetiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For Inlection WeHl 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: ry construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 AZa11 Service Center,Raleigh,NC 27699-1636
i
13e.Yield(gpm) 1 Method of test: Air 24c.For Water Supply&Iniection Wells:
Also submit one copy of this fort i within 30 days of completion of
13b.Dlslnfection type:
Granular Amount: 1/2 lb.
well construction to the county health;department of the county where
constructed.
Forni OW-1 North Carolina Department of Euviroiumnit and Natural Resources—Division of Water Resources Revised August 2013