GW1-2021-00695_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:
14.WATER ZONES
Dwight L. Huneycutt FROM TO I DESCRIPTION
Well Contractor Name 230 1" 240 ft 1 45 gpm
4070-A ft I f6
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft• 80 fr 61/8 "- 1 SDR-21 I PVC
Company Name I&INNER CASING OR TUBING(geothermal closed-loop)
Parcel# 3843 FROM I To I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL FL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7£ THICKNESS MATERIAL.
OAgricultural ❑MunicipaUPublic ft. tt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tL in
❑IndustriaUCommercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 It. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rL 35 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
F20.
OM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fL
❑Experimental Technology ❑Subsidence Control
DRTLLING LOG attach addidanalaheets if necessa❑Geothermal(Closed Loop) ❑Tracer OM TO DESCRIPTION color,haHnes,%soil/mck type,grain sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 & 22 ft. Red Dirt
4.Date Well(s)Completed: 9/4/21 Well Em Well # 3 22 f- 55 ft. Brown Sandy Dirt
55 ft. 69 ft. Brown Granite
5a.well Location: 69 r` 325 n Gray Granite
Aaron Brown ft. ft.
Facility/Owner Name Facility iD#(if applicable)
6981 Airport Rd., Bear Creek 27207 ft a. Seams: 112', 118', 138-142', 195',230',=45g
ft. ft 250%292'
Physical Address,City,and Zip _
21.REMARKS r
Chatham 3843i.-
County Parcel Identification No.(PiN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W LtaXLt,�, 9/30/21
Signature of eertified Well Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby ceritfy that+the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing we1L• ❑Yes Or ONO 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 same conslructiaa,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 Ifdiflerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 36 (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniectfon 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) 45 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Granular Amount 1�2 Ili• 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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