GW1-2021-00811_Well Construction - GW1_20211208

'WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
John W. Huneycutt FR WATER ZONES
Y FROM TO DESCRIPTION
9✓ell Contractor Name 102 rt• 110 rL 30 gpm
�2465-A ft fL
NC Well Contractor Certification Number 15.OUTER CASING for mold cased wells OR LINER f a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 rL 46 rt 61/8 ! 1n SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
THICKNESS MATERIAL
�.Well Constriction Permit#: 21-124 FROM ft. TO ft. DIAMETER in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
13.Well Use(check well use): 17.SCREEN
ater Supply Well: FROM To DIAMETER SLOT SUE THICKNESS MATERIAL
7fL
Agricultural ❑Municipal/Public ft.ft. ft. rn
:]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 it. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 fL Bentonite Pumped
njection Well: fL M
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM tt 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,bzrdnfts,soilfrock type,gritin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft. 15 ft Brown Dirt
4.Date Well(s)Completed: 7/22/21 Well ID# 15 tt. 20 ft Brown Rock
20 ft 125 Blue Rock
So.Well Location:
Emerald Pointe Realty fL ft.
Facility/Owner Name Facility ID#(if applicable) ft R
6214 Olive Branch Rd.,Wingate 28174(Griffin Estates Lt10) Seams:50',70',85',,8T,t02'=30gpin— ?
Physical Address,City,and Zip 21.REMARKS
Union 02199005W l
County Parcel Identification No.(PIN)
�5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) / J
N w � ' 8t'15/21
Sign,0WrofCmficdWclI Contractor V Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)ivas(were)constmeted in accordance
ivith 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair tinder#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 construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 125 (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: 28 (ft.) Division of Water Resources,Information Processing Unit,
If eater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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) 30 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 Environment and Natural Resources—Division of Water(sources Revised August 2013