GW1-2021-04466_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 4
This fonn can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Dwight L. Huneycuff FROM TO DESCRIPTION
Well Contractor Name vaY 288 n' 295 n' 3 gpm
4070-A ��� �'� n. (L
NC Well Contractor Certification Number 9 ER CASING for multi cased bells OR LINER H e Ilcable
I OM Tn AIA117ETER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. � ncpl 0 n 72 n 6 1/8 in SDR-21 I PVC
Company Name 4 Se 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: 2020-0000211�ts_4� ��p\T,� FROMn TO n DIAMETER In. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Inje on,etc.)
n. n. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
tt• n• In.
❑Agricultural ❑Municipal/Public
❑Gcoth anal(Heating/CoolingSupply) Mcsidential Water SuPP1Y(single)
❑bidustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Iri ation 0 n. 3 n• Bent.Chips Gravity
Non-Water Supply Well;
❑Monitoring ❑Recoy 3 n' 20 n Bentonita Pumped
Injection Well:
❑Aquifer Recharge ❑Groundwater Rcmedistion 19.SAND/GRAVEL PACK if a Ileable
FROM❑Aquifer Storage and Recovery ❑Salinity Barrier
TO n MATERIAL E11II'LACE2�IPI'DiETHOD❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
20.DRILLING LOG attach additional sheets 1<necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,harftesi6 soillrock tyM grWn size etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 n' 28 n. I Red Clay
4.Date Well(s)Completed: 8/19/20 Wel11D# 28 n 59 n. Brown Dirt
59 n 400 n Blue Granite
Sa.Well Location:
Johnny Lineberger
Facility/Otwer Name Facility IDi;(if applicable)
Ralph Lawrence Rd., Seagrove 27341 rt. Seams: 149', 15T,280',288'=3g
Physical Address,City,and Zip 21.REMARKS
Randolph 7684150431
Comity Parcel Identification No.(PIN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field one Ist/long is sufficient)
N W % f,�, 7/2/20
Signature of Certified Well Contractor Date
6.Is(are)the well(s): GdPermiment or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC'01C.0100 Well Constniction Standards and that a
7.Is this a repair to an existing well: ❑Yea or Mo copy ofthis record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remarks section or on the back ofthis 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 Writ the sanm construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 400 (n.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(exompla-3@200'and 2@100') construction to the following:
35 Division of Water Resources,Information Processing Unit,
10.Static water level below top of easing:
If nmter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter- 6 (lq.) 24b.For Injection 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
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Iniection 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 health i1cpartruent of the county where
constructed.
Fonu GW-I North Carolina Department of Eaviromuent and Natural Resources—Division of Water Resources Revised August 2013