GW1-2021-04526_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: fl
Dwight L. Huneycutt REC 14.WATER ZONES
FROM TO DESCRIPTION I
Well Contractor Name 237 ft. 244 ft. 4 gprn
4070-A APR 2 9 2021 rL «.
NC Well Contractor Certification Number i art�rOCDSSICif�U 1 5.OUTER CASING for multi cased wells OR LINER if a livable
Ifi1:,l11�3 ; FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. p1NR se Ion 0 rL 144 ft 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
20-460 FROM TO DIAMETER) THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count),,State,Varionce,Injection,etc.)
ft. ft. jin.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ISLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) «' ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIALi EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 «. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3' «• 35 It- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG a«ach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,gnin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 13 ft. Brown Dirt
4.Date Well(s)Completed: 3/5/21 Well ID# 13 f` 300 « Slate
5a.Well Location:
Donna Brooks ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:71',77',90',98',237'=4g,
5217 E Lawyers Rd, Wingate 28174 (Lt1) rt. rL
275'
Physical Address,City,and Zip 11.REMARKS
Union 02199006K
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 D •�•-• 7'av`f 3/25/21
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby certify that!the well(s)it-as(here)constructed in accordance
udth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KIND copy ofthis record has been provided to the ns//owner.
If this is a repair,fill out k»own well construction information and explain the nature oflhe
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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-vrater supple yells ONLI'with the same construction,you can
submit one form. SUBMITTAL 1NSTUCTIONS
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9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni/(example-3@200'and 2@100) construction to the following:
35 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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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 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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield m 4 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resotu-ces Revised August 2013
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