GW1-2021-04520_Well Construction - GW1_20210429

E
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt q 14.WATER ZONES 1
FROM TO DESCRIPTION
Well Contractor Name 152 ft' 155 ft' 5 gpm
4070-A n 2 9 2021 ft. ft. j
NC Well Contractor Certification Number ApR 15.OUTER CASING for multi-cased wells OR LINER if a livable
�AUnt FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,3;toT1 Pro o ft. 45 ft- 6 1/8 in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
20-502 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable uvell 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 THICKNESS MATERIAL
ft. ft.❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑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:
3 ft. 35 ft- Bentonife Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rack type,Min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 23 ft. Brown Dirt/Rock
1/21/21 23 ft. 245 ft. Slate
4.Date Well(s)Completed: Well ID#
rt. rt.
59.Well Location: ft. ft.
Austin Hills LLC
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
5904 Ruffner Ct., Wingate 28174 (Austin Hills Lt27) Seams:57',88', 115', 152'=5g
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 02199048
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 2/10/21
Signature of Certified Well Contractor tv Date
6.Is(are)the well(s): IZPermanent or ❑Temporary
By signing this form,1 hereby cerhJv that the ivep(s)ryas(were)constructed in accordance
nvth 15A 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 ElNo copy of this record has been provided to thi>,nvell owner.
If this is a repair,fill out kwonvn well construction information and explain the nature of the
repair under 921 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-neater supply nvells ONLY With the saute construction,von can
submit one form. SUBM17TAL 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 nvells list all depths ifdii Brent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 26 Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: [f
(i.e.auger,rotary,cable,direct push,etc.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 5 Method of test: Air 24c.For Water Supply&Injection Wells:
(gP ) 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 health(department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Re ouices Revised August 2013