GW1-2021-04522_Well Construction - GW1_20210429

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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:
Dwight L. Huneycutt 14.WATER ZONES '
g Y FROM TO DESCRIPTION
Well Contractor Name d ..� 155 ft' 160 tt. 5 gpm
4070-A � 1 212 IL 218 ft. 10 gpm
NC Well Contractor Certification Number n p 2 g 202 15.OUTER CASING for multi-cased wells TO LINER if a licable
p f� FROM TO DIAMETER i THICI4�ESS MATERIAL
Derry's Well Drilling, Inc. �Pss�n9Unt� 0 ft- 61 ft• 61/8 1 i" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-503�r1{c VIryIR FROM TO DIAMETER THICKNESS MATERIAL
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 THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaVPublic
ft. 1L in.
❑Geothermal(Heating/Cooling Supply) ZIResidential Water SuPP1Y(single)
❑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 rt. 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERAAI. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
tt. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Traee7 FROM TO DESCRIPTION color,hardness soil/rock 'in s etc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 fL 17 ft. Red Clay
4.Date Well s)Completed: 2/25/21 Well ID# 17 ft' 45 ft. Brown Dirt
( P 45 ft. 245 ft. Slate
5a.Well Location: ft.
ft.
Union Homes LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)1710 McIntyre Rd., Wingate 28174 (McIntyre Est Lt4) ft. ft. Seams:69', 111', 155'=5g,212'=10g
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 09009002F
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)
3/15/21
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thai the uvll(s),vas twere)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E-11No copy ofthis record has been provided to the iwll owner.
If this is a repair,fill out knoww well construction information and explain the nature of the
repair under#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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple 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: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple n'ells list all depths ifdifferent(example-3@200'and 1@100� Construction to the following:
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10.Static water level below top of casing:
29 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above casing,use"+" 1617 Mail Service Center,
ter,Raleigh,NC 27699-1617
11.Borehole diameter:
6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of t h is!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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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m 13a.Yield
(gP ) 15 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this for within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county healthi department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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