GW1-2021-00816_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
14. ONES
John W. Huneycutt FR MATER TODESCRIPnON
Well Contractor Nante 86 R• 88 2 gpm
2465-A 150 ft 170 rt 4 gpm
NC Well Contractor Certification Number 15.OUTER CASING for maltycased wells OR LINER tf a Dyeable
FROM TO DIAMETER THICIQm'ESS MATERIAL
Derry's Well Drilling, Inc. 0 R 148 h 61/8 ;'° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-130 FROM TO DIAML-FM THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in.
List all applicable well permits(i.e.Counly,State,Variance,Injection,etc.) ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S12E THICKNESS MATERIAL
ft.❑Agricultural ❑Municipal/Public ft. in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) tt• (L in.
❑Industrial/Commemial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT hIETHOD&AMOUNT
OIrrigation Non-Water er Supply Well: 0 n• 3 R• Bent.Chips Gravity
❑Monitoring ❑Recovery 3 n 35 R Bentonite Pumped
Injection Well: n R
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Dcable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Fxpc imental Technology Cl Subsidence Control
20.DRILLING LOG attach additional sheets if Deeps
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION mlor hardness,soilfrock t3Te etc)
❑Geothermal(HcatinglCooliM Return) ❑Other a lain under#21 Remarks 0 n 9 R Brown Dirt
7/21/21 9 R 27 �� Brown Rock
4.Date Well(s)Completed: Well ID#
27 225 n Blue Rock
5a.Well Location: R g
Emerald Pointe Realty ft. R.
Facifty/Owuer Name Facility ID#(if applicable) g ft•
Seams:51',65',.86'=2g;90',11Z,;•11T,
6216 Olive Branch Rd., Wingate 28174 (Griffin Est Lt 11) 150-170'=49;201'
Physical Address,City,and Zip
21.REMARKS
Union 02-199-005X
Comity 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 (�{/ 9/14/21
*06 of Certified Well Contractor Date
6.Is(are)the well(s): 101 ermanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)tvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this record has been provided to the troll 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-tvater supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 42 (g,) Division of Water Resources,Information Processing Unit,
If outer level is above casing,rise"+' 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
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:
(Le.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
139.Yield(gpm)
6 Method of test: Air 24c.For Water Supply&Iniection,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-1 North Carolina Department of Environutcut and Natural Resources—Division of Water Resources Revised August 2013