GW1-2022-10075_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES C
Dwight L. Huneycutt FROM TO I DESCRIPTION I
Well Contractor Name 102 it' 105 ft. I I 1 gpm
4070-A °,� _ 370 f- 375 ft 2 9p►n
NC Well Contractor Certification Number ,E c'r iz a v' a + 15.OUTER CASING for multi cased wells OR LINER it a dicahle
FROM TO DIAMETER TiiICIQ`IESS IiI1TERMAL
Derry's Well Drilling, Inc. NOV 0 7 202 0 - ft' 1S2 ft' 61/8 'SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eother at closed-loop)
22-161WOr zr,an Prncun4ftJ Unit FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft.
List all applicable well permits(i.e.County,Stare,Variance,Injhltldn J-.) ft. ft. in. I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS IifATER1AL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) aResidcntial Water Supply(single) ft rt. m.
❑htdustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT'
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 tt Bent.Chips, Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 it. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK:if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock rain siu etc)
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 0 B- 13 ft. i• Red Dirt
5/14/22 13 ft 600 ft Slate
4.Date Well(s)Completed: Well ID# ft. ft.
Sa.Well Location: ft ft.
Tony Medlin ft. ft.
Seams:60,,88, 102—1 gpm, 115, 130, 135,
Facility/Owner Name Facility lD#(if applicable) ft. it. 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)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) q�
N W i " 6/11/22
Signature Well Contractor Date
6.Is(are)the wcll(s): OPermanent or ❑Temporary By signing this form,I hereby certify that die wells)ivas(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC.02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy afthis record has been provided to the iWl owner.
If this is a repair,fill out known well construction information and explain tine nature of the i
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,1to 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 hyeclion or non-water supply wells ONLY with the same construction,you can
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 ifdffferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,information Processing Unit,
Iftvater level is above casing,use"+^ 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection:Wells:
Also submit one copy of this fortis within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb• well construction to the county heath department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Wat I I Resources Revised August 2013
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