GW1-2021-04472_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells k4
1.Well Contractor Information: tti�tt.�
.John W. Huneycutt �� OI.` WATER ZONES
,I OM TO DESCRIPTION
Well Contractor Name Qe�I�Q`��,eo 320 n• 326 n• { 1 gpm
246a-•A
NC Wall Contractor Certification Number �.�� �e 15.OUTER CASING for multl-tased wells OR LWER P a Rceble
FROM TO DIM7t 1'ER TffiCKNESS MATERIAL
Derry's Well Drilling, Inc. ��� �� 0 n 63 n 61/8 1'n SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00000763 FROM TO DIAMETER THICENESS MATERIAL
2.Well Construction Permit#: V 4! V 4 4! I n. n. i la.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIcle4m MATERIAL
n. n.
❑Agricultural QMunicipal/Public
❑Geothermal(Heating/Cooling Supply) OResidcntial Water Supply(single) n n• In'
❑Industrial/Commereial QResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPIACEMEAT METHOD&AMOUNT
❑kri ation 0 n' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring QRecov 3 n' 20 n' BltntOflltt3 Pumped
b4ecdon Well:
❑Aquifer Recharge QGroundwater Rerrlediation 19.SAND/GRAVEL PACK if applicable)
FROM TO DtATER1AI, I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery QSalinity Barrier
[]Aquifer Test QStormwater Drainage
n. n.
QExperimental Technology El Subsidence Control
20.DRILLING LOG attach additional sheets it uecessa
❑Geothermal(Closed Loop) QTraeer FROM TO DESCREMON color,hardness,soil/rock type,ffraln size etc.
QGcothermal (Heating/Coolie Rctum QOther(explain under#21 Remarks 0 n' 28 n' Brown Dirt
12/30/20 28 n 49 n Brown Rock
4.Date Well(s)Completed: Well ID#
49 n 405 n Blue Rock
5s.Well Location:
Eric Marshall
Facility/Owner Name Facility tD#(if applicable) n, n. Beams: 94', 156',245'=1 g,295',
2782 East Fork Dr., Seagrove 27341 n. n _
320,-1g
Physical Address,City,and Zip 21.REMARKS
Randolph 7695382290
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cet7Z i
(if well field,one lat/long is sufficient) /
Y r 1/20/21
N W a)
Signatu of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that'rhe imil(s)ivas(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Consirtiction 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.
If this is a repair,fill out knouts well construction information and explain the nature of the
repair tinder#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 some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diifferant(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:
36 Division of Water Resources,Information Processing Unit,
(ft.)
Ifwater level is above casing,use"+^ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (In.) 24b.For Injection Wells ONLY: 16 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Mectlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test- Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form lwithin 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.
Faint OW-t North Carolina Department of Eavirimment end Natural Resources—Division of Water Resources Revised August 2013