GW1-2021-00694_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I I i
Dwight L. Huneycutt 14.WATERZONES
g Y FROM TO I DESCRIPTION
Well Contractor Name 238 fL 245 ft. r 22 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 85 ft. 61/8 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
Parcel# 3843 FROM TO DIAMETER THICKNM MATERIAL
2.Well Construction Permit#: ft. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑MunicipaUPublic ft ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 n' 3 fr. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soillrack type,grain shr,etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 f6 26 ft. Red Dirt
4.bate Well(s)Completed: Well EN9/6/21 Well #4 26 ft• 58 ft. Brown Sandy Dirt
58 R- 70 ft. Brown Granite
5a.Well Location: 70 ft 325 fL Gray Granite
Aaron Brown
ft. e.
Facility/Owner Name Facility ID#(if applicable)
6981 Airport Rd., Bear Creek 27207 Seams:93',97', 1102V_1129l 15�o',
fr. ft. 1TL
238—22g
Physical Address,City,and Zip ,
21.REMARKS
Chatham 3843
County Parcel Identification No.(PIN) 11.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification l
(if well field,one lat(tong is sufficient)
N W � J ' 9/30/21
Signature o Certified Well Contractor Cl Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
If this is a repair,Jill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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 same construction,you can
submit one form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 37 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Iniection 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 22 Method of test: Air 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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