GW1-2021-04474_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For imernal Use ONLY: i
This form can be used for single or multiple wells
1.We"Contractor Information: p� °�
John W. Huneycutt l��JJ, 14.OWATER ONES
MM DFSCRUTION
Well Contractor Name 1• 319 n• 325 n 10 gpm
ti SO
2465-A PQ� o�e� n. n.
15.OUTER CASING for Taid sed wells OR LINER it applicable)
NC Well Contractor Certification Number �A e
S FROM TO D[AAfETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,A��c�' O`� 0 n' 83 n• 6 1/8 !in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
FROM TO DIAMETER THICKNESS DATERIAL
2.Well Construction Permit#: R. n. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
n, n, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DiAAWTRR SLOT SIZE THICKNESS MATERIAL
(ZAgricultural ❑MunicipallPublic
❑Qeothetmal( cati Conlin Supply) ❑Residential Water Supply(single) n n• in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 n' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Rccov 3 n' 35 n' Bentonite Pumped
Infection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO DATERIAL EMPLACEMEW METHOD
❑Aquifer Storage and Recovery ❑Salinity,Barrier n. n.
❑Aquifer Test ❑Stormwatcr Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additionei sheets R necessary)
❑Gcothe nal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bean soil/rock type,grato size etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 It. 66 n Brown Dirt
n' n
4.Date Well 1/20/21 s)Completed: Well� 66 345 Granite
Sa.Well Location:
Steven King
Facility/Owner Name Facility ID#(if applicable)
n. n' Seams: 154', 196',265',319'=10g
Hoover Grove Rd., Denton 2223`�
n. n.
Physical Address,City,and Zip 21.REMARKS
Randolph 7700645272
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaVlong is sufficient) / ���� //
1� (i(/. 1/26/21
N W �1
S' tore of Certified Well Contract Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yea or 9]No copy of this record has been provided to the well owner.
If this is a repair,fill out known 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 soma construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- 345 fft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(Jerent(example-9@200'and 2@1001 construction to the following:
26 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
if tooter level is above casing,use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For kolection 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: ry construction to the following: 4
(i.e.auger,rotary,cable,direct push,etc.) I
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) 10 Method of test• Air 24c.For Water Supply At Iniection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county health department of the county where
constructed.
Fonu OW-t North Carolina Department of Environment and Natural Resources—Division of Water Rel ources Revised August 2013
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