GW1-2021-05875_Well Construction - GW1_20210709

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 01—® j
1.Well Contractor information:�Qtl
John W. Huneycutt ^++ 14.WATER ZONES
Y n (� oft FROM I TO I DESCRIPTION
Well Contractor Name J v C U��t 85 ft- 190 fL 1 3 gpm
2465-A �tOvggS�n9 290 ft- 296 fL 1 3 9pm
{ ,3 $v� I&OUTER CASING for multi cased wells OR LINER if a livable
NC Well Contractor Certification Number 1rls`�l p�,rdR J FROM TO DIAMETER TIRCIC ESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 44 ft• 61/8 ; ir' SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
20-601 FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: f[. R. In.
List all applicable well permits rt.e.County,State,Variance,Injection,etc.)
ft. tL I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public fL ft in.
❑Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) fL fL in.
❑industrial/Commercial []Residential Water Supply(shared) Is.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Trci ation 0 fL 3 rL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R tt
❑Aquifer Test ❑Stormwater Drainage
fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRIPTION color,hardness,soillrock type,zrain sim,eta
[]Geothermal Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 11 fL Red Dirt
5/21/21 fL 25 fL Brown Dirt
4.Date Well(s)Completed: Well iD# 11 25 fL 400 fL Blue Rock
5a.Well Location: it. fL
Alexsander Garcia fL It.
Facility/Owner Name Facility iD#(if applicable)
3020 Brooks Mill Ln.,Wingate 28174(Olive Branch Est Lt 30A) fc & Seams:85-90'=3g,150', 187',230',
& 290'=3g,306',365'
Physical Address,City.and Zip 21•REMARKS
Union 02230025
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degreeshWnutes/seconds or decimal degrees: 22.Certification:
(ifwell field one lat/long is sufficient) U/) rn,(//I - `NNg4t& 6/12121
Sign of'Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Ay signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC C 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ENO copy tfthis 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 ii2l 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.
Par 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: 400 (ft.) 24a. For All Wells: Submit this Iform within 30 days of completion of well
Par multiple wells list all depths ifdoerent(example-3@200'and 2@/00') construction to the following: '
10.Static water level below top of casing: 38 (ft) Division of Water Resources,information Processing Unit,
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: To addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,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) 6 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.
i
Form OW-i North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013
i !
1