GW1-2021-05876_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY- i
This form can be used for single or mulliple wells I
t.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES I
FROM TO DESCRIPTION i '.
Well Contractor Name 230 fr• 235 fr• 2 gym
4070-A O �021 fr. ft.
Ju� voil F15R.O OUTER CASING for mt-cEwells'ORN a icable
IAMNCµell Contracts'Certification Number DLITERLIL
Derry's Well Drilling, Inc- procQ+�sln9 0 fr• 51 fr. 6 1/8 i1 SDR-21 PVC
Company Name �rl ' D�f1 j� 16.INNER CASING OR TURING eothernwl closed-loop)
21-12 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft.
List all applicable well permits(i.e.Counlp,State,I'ariancc,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sinele) ft. ft.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUP
FROM TO MATERIAL EMPLACEMENT METHOD R AMOUNT
❑Teri ation 0 rt. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fr. 35 ft- Bentonite Pumped
Injection Well: fr. fr.
❑Aquifer Recharge ❑Grotnldwater Remediation 19.SAND/GRAVEL PACK: if applicable)
FROM TO M.ATERLIL EMPLACEMENT METHOD
❑Aquifer Storage and Recover}' ❑Saliniy Barrier ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.snit/rock typ,gmin,i-,etc.)
❑Geothermal(Heating/CoolingReturn) 00ther(explain under#21 Remarks) 0 fr' 18 fr• Brown Dirt
4/13/21 18 fr. 25 fr• Brown Rock
4.Date Well(s)Completed: Well it)#
25 ft• 450 fr• Slate
5a.Well Location:
Justin Crowell
Facility/OwnerNatne Facility KD=(ifapplicable) ft. ft
1420 Crowell Dairy Rd., Indian Trail 28079 ft fr Seams:61', 114', 147', 178',212',
230-235'=2g
Plivsical Address,City.and Zip 21 RENIAR6.S
Union 08282010E
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)
N W 5/1/21
Signature o Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By'.si),ming this/itrm, I hereby certo,that the wel/(s)urns(it-ere)constructed in occ•ordmtce
with 15A NCA(:'02C.0100 or 15A N(AC 02(`.0200 Well Consintelion Slan dards and that a
7.is this a repair to an existing well: ❑Yes or E]No copy ey'thts record has been prorided to the well owner.
I(thi.s is a repair,fill nut known well comfruction information and explain the nature u)'the
repair under:121 remarks section or on the back of 1hi.s fhrnc 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-u oter supply wel/s ONLY with llie same canstruc6nn.you can
suhrint anef nIn. SUBMiTTAL iNSTUCTiONS
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9.Total well depth below land surface: 450 (ft.) 24a. For All Wells: Submit this form within N days of completion of well
Par nnitiple wells list all depths ijdilfereni(example-3@200•and 2@100) construction to the following:
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10.Static water level below top of casing: 45 Division of Water Resources,information Processing iTnit,
Ifwater level is abtn'e casing.use"+ 1617 Afail 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
24a above, also submit a copy of this 1tonn within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,iotaiv.cahle.direct push,etc.)
Division of Water Resources,Underground injection Control Program,
—.._-_.....__..-.__--'--.__..-..-._.. u:xr.am;e c.s�,..,C-,.nr..:• o..e,.;nt, yr�+sno rt2r.
11'Va\\iH 1L'1\Jl'll L1 •1LLLJ V!•L1: I - -- —��- �-� -�-- -4 ---- - - -- -- -_-
1 7 A I 2� T \1 r Supply
l!i.. \':.,I.t t L \,t..,r....l..r♦ llll I u1i
Also submit one coDc of this form within 30 da_cs of completion of
i Ijrani rust t� t� i ell io_ ,':e health d ado •it :1-the co. .."here
1 1'tb llic:nfors'rnn t\•nn• ,I mn.oh 1/� II,J. i •••. ••,,,.••,n" - •,�••• el,t : �
Form tiw-I NortIt Caroiina Denarunent of EuvironmenI and-Natural Resources-Division of awl Kesourees Revised Ainiusi_u i S
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