GW1-2021-00697_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.
Dwight L. Huneycutt FROWATER ZONES DESCRIPTION
Well Contractor Name 270 1" 276 ft• 112 gpm
4070-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licahle
FROM TO DIAMETER THICIQVESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 90 ft 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
Parcel#3843 FROM TO DIAMETER TMCKNESS MATERIAL
2.Well Construction Permit#: k. ft in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
k. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I' ft im
DAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irrl ation 0 ft ft.
3 Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 35 k- Bentonite Pumped
Injection Well: k. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL I I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soturock type,grains etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 k' 28 fL Red Dirt
4.Date Well(s)Completed: 9/2/21 Well ID# Well # 1 28 IL 70 ft. Brown Sandy Dirt
70 fL 83 k• Brown Granite
5a.Well Location: 83 1" 350 f Gray Granite
Aaron Brown ft. ft
Facility/Owner Name Facility tD#(ifapplicable) fL IL Seams: 114', 128-132', 142', 155',
6981 Airport Rd., Bear Creek 27207
Physical Address,City,and Zip k. 193',270'=12g
21.REMARKS
Chatham 3843
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification' DEC o 8 2 2(if w Wong field,one ong is sufficient)
9/30/211
Signature f Certified Well Contractor Date '
u lJi`:1
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was'(wereJ cost iructed in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to the well owner.
If this is a repair,fell out known well construction information and explain the nature of the
repair under#21 remarks 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 wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 350 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 41 (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 Infection 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
11.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) 12 Method of test: Air 24c.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 lb. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Envirommnt and Natural Resources—Division of Water Resources Revised August 2013