GW1-2021-04469_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 4,
1.Well Contractor Information: ��
Dwight L. Huneycutt tLy 1R.WATER zoNES
FROAi TO DFSCRIP'RON
Well Contractor Name g 372 n 376 n I 2 gpm
4070-A PQ� t��eh�a� 650 n 660 'L 3 gpm
NC Well Contractor Certification Number �e �, ' 15.OUTER CASING for multi-cased wells TO LINER If a Arable
S FROM TO DIAMETER TffiCKNESS DfATERIAL
Derry's Well Drilling, Inc. ����• p� 0 n 63 n 61/8 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
2015-00001�i82 FROM TO DIAMETER TTTICKNESS MATERIAL
2.Well Construcdoa Permit#: n. n. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
n. n. to.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TBICKNESS MATTIHAL
Agricultural icipal/Public A. n in.
❑ ClMun
❑Gcothennal(Heating/Cooling Supply) 9lRasldcntial Water Supply(singlc) n' ft.
in.
❑IndustriaUCammercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ini ation 0 n. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
[]Monitoring DRecovay 3 n' 20 n Bentonite Pumped
Infection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquiftt FROM TO MATERUL EMPLACEMENT METHOD Storage and Recovery ❑Salinity Barrier n. n.
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/rock type,grain size etc.
❑Geothermal (Heating/Cooling Return ❑Othcr(explain under#21 Remarks 0 n' 9 n' Brown Dirt
4.Date Well(s)Completed: 8/4/20 Well ID# 9 n, 41 n. Boulders
41 n 50 n Brown Dirt
So.Well Location: 50 n 785 n Blue Granite
Eric Kozlow
n. n.
Facility/Owner Name Facility ID#(if applicable) n, n• Seams: 112', 136',372-376'=2g,
1425 Fawn Dr., Asheboro 27205
n. n. 650'=3g
Physical Address,City,and Zip
21.REMARKS
Randolph 7742842771
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certifleadon:
(if well field,one let/long is sufficient)
N W 8/15/20
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 1OPermoneut or ❑Temparary By signing this form,I hereby certify that the well(s)was(wore)constructed in accordance
with 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 ONo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair tinder#21 remorks 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 walls ONLY with the scone construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7$5 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a(�200 and 2@100) construction to the following:
10.Static water level below top of casing: 45 Division of Water Resources,Information Processing Unit,
If,vater level is above Casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (►n,) 24b.For Iniection 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.Wen construction method: Rotary 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(gpm) 5 Method of test Air 24c.For Water Supply&Iniection Wells:
Also submit one copy of this forms within 30 days of completion of
13b,Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
Few OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013