GW1-2022-04273_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name r� 1 75 ft- 85 ft. 10 gpm
2465-A ft. ft.
NC Well Contractor Certification Number fl P 0 201? 15.OUTER CASING for multi cased wells OR LINER if a licahle
A 0 �' FROM TO DIAMETER', THICKNESS1 MATERIAL
Derry's Well Drilling, Inc. 0 ft' 46 ft 6 u8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#• ;.,.,,,�1�na� ''ai�• ft.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well•- FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 tt. 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 35 It- BentOnite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑ FROM TO Aquifer Storage and Recovery ❑Salinity Barrier & fr. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
I, ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,seiVmck type,Krain s' etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 16 ft. Brown Dirt
4.Date Well(s)Completed: 1/12/22 Well ID# 16 ft- 24 ft. Brown Rock
24 ft• 185 f` Slate
5a.Well Location: ft. ft.
Jacob Tarlton ft %
Facility/Owner Name Facility ID#(if applicable)
5209 Lawyers Rd E, Wingate 28174 L, -�- �� f Seams: 56',75-85'=10g, 110', 143'
Physical Address,City,and Zip 21.REMARKS
Union 02199006M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one fat/long is sufficient)
N w � w• Y r uyyQ.�11�- 2/5/22
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(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 0No 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i#different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 19 (110 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 10 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular well construction to the county health department of the county where
136.Disinfection type: Amount: 1�2 lb. �
constructed.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013