GW1-2021-05873_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells i
I.Well Contractor information:
John W. Huneycutt ��t�,�1 FR WATER ZONES
o � RR OM TO I DESCRIPTION
Well Contractor Name 2p21 336 fL340 fL 2 gpm
2465-A Jul fL
NC Well Contractor Certification Number �e�gl(19 unl� 15.OUTER CASING for multi cased wells OR LINER if a livable
���jCO' FROM TO DIAMETER THIC[aVP,SS IitATEAIAi.
Derry's Well Drilling, Inc. irfior ��Z S'8" on 0 ft 46 ft- 61/8 i'" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
21-108 FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. irk.
List all applicable well permits(.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SEE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL R in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) IL ft
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ii ri ation 0 fL 3 fit. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 ft- Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa icable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neema
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soiVrmk tyM grain size,eta
❑Geothermal Heating/CoolingRetum) ❑Other(explain under#21 Remarks) 0 f• 19 ft Brown Dirt
6/4/21 19 fit 400 ft Slate
4.Date Weil(s)Completed: Well i W
fL ft.
Sa.Well Location: fL fL
Austin Hills LLC fir. fL
Facility/Owner Name Facility iD#(ifapplicable) ft. &
2318 Louanne Dr., Wingate 28174 (Austin Hills Lt 38) Seams:70', 147',255',336'=2g,370'
FL ft 390'
Physical Address,City,and Zip 21.RENIARKS
Union 02199059
County Parcel identification No.(PiK)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W & (,(� � � 6/22/21
SiF64re ot'Certrtied Well Contractor(/ Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this form.l hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A N(:AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or AND copy[fthis record has been provided to the well owner.
If this is a repair,fill out krunm well canstruction information and explain the nature of the
repair under ii21 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.
Nor multiple Injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUMONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths lfdiJjerent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 46 (ft.) Division of Water Resources,information Processing Unit,
lf,rarerlevel 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 WEIRS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 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 Resources Revised August 2013
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