GW1-2021-00759_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:
Huneycutt 14.WATER ZONES
John W. Hune
Y FROM TO DESCRIPTION
Well Contractor Name 170 f" 175 fr 1 gpm
2465-A 292 ft. 300 ft. 1 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER: THICIaIESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 42 fL 6 1/8 'in• I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00001760 FROM ft.
DIAMETER THICKNESS MATERL
2.Well Constriction Permit#: ft. i"• IA
List all applicable well permits(t.e.County,State,Variance,injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER BLOT SIZE THICKNESS MATERIAL
TL f6 in.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. rn
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irr; ation 0 rL 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL 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 soil/rock type rain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 7 ft. Brown Dirt
9/10/21 7 fL 18 ft. Brown Rock
4.Date Well(s)Completed: Well ID#
18 ft. 405 ft• Blue Rock
5a.Well Location: R. g•
Steven Hunt ft. ft.
Facility/Owner Name Facility iD#(if applicable)
Seams:56', 125', 137', 154', 170'=19,
3428 Old Red Cross Rd., Climax 27233 �' ft
ft ft. 225',292'=1g,335,395'
Physical Address,City,and Zip 21.REMARKS
Randolph 7797784812 -
County Parcel Identification No.(PiN) DEC 0 Q
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
U
(ifwell field,one Wong is sufficient) �
N W �LUZLyl�- i' n�tit110/10/21 ,
SiVre of Certified Well Contractor Date
6.is(are)the well(s): 101'ermanent or ❑Temporary By,signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or [KIND 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 421 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 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 ij different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 38 (ft) 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 Iijection 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,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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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