GW1-2022-10071_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD For Internal Use ONLY: I j
This form can be used for single or multiple wells IfI
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES,
g Y FROM To DESCRDPTION!
Well Contractor Name �. 102 f" 105 fL I 1 gpm
4070-A �' s , . 370 ft. 375 ft i 2 gpm
NC Well Contractor Certification Number NOV 07 2022 15.OUTER CASING for multi cased wells OR LINER if a licable
N FROM TO DIAMETER' T1LC[4VESS MATERIAL
Derry's Well Drilling, Inc. Un, 0 ft 52 ft 61/8 ice' 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING. eothermal closed-loo
22-1611 � FROM R'' TO DIAMETE • THICKNESS MATERIAL
2.Well Construction Permit 4: ft. ft. in.
List all applicable well permits 0.e.County,State,Variance,Injection,etc.)
ft ft, i is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER !'SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft in
❑Industiial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft Bent.Chi'ps Gravity
Non-Water Supply Well:,
❑Monitoring ❑Recovery 3 % 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable .
FROM TO MATERIAL. J EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional'aheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soil/rock type dm eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 13 ft. i Red Dirt
5/14/22 13 ft 600 ft •Slate
4.Date Well(s)Completed: Well ID## fL tt
Sa.Well Location: ft ft.
Tony Medlin ft rt ,
Facility/Owner Name Facility IDH(ifapplicable) Seams:60,88, 102'=1 gpm, 115,130, 135,
ft ft 153', 164','175',229'.240',271',298',350',
1412 Ellis Griffin Rd., Wingate 28174 ft ft ,
370'=2gpm,387,418,447,498'
Physical Address,City,and Zip
21.REMARKS
Union 02236005A
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one lat/long is sufficient)
N W ly/z 6/11/22
Signature o Certified Well Contractor V Date
6.IS(are)the well(s): Permanent Or ❑Temporary By signing this form,I hereby certo that(the wells)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: 1JYes or ONO copy ofthis 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
S.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 j
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface., 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'•+^ 1617 Mail Service Ce Iter,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 dais'form within 30 days of completion of well
12.Well construction method: construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce(ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forml 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 Environment and Natural Resources—Division of Water Resou[ces Revised August 2013