GW1-2021-05881_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY: l
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ® 313 fL 318 fL 2 9pm
4070-A �j fL fL l
�� tioti�
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
0 V � FROM TO DIAMETER I TIQCKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 55 ft- 61/8 SDR-21 I PVC
Company Name rt 16.1NNER CASING OR TUBING eothermal closed-loop)
'J`�pC� Cev FROM TO DIAMETER THICKNESS MATERIAL
21-16
2.Well Construction Permit#: f0�0;t�tX ft. R. in
List all applicable well permits rice.Counly,State,variance,Injection,etc.)
R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Municipal/Pubtic
❑Geothermal(Heating/Cooling Supply) KlResidential Water Supply(single) ft. fL in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 f" 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft. 35 fL Bentonite Pumped
❑Monitoring ❑Recovery
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
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnen,soilltock tyM gmin size,etc
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 13 fL Red Clay
4.Date Well(s)Completed: 4/22/21 Well iD# 13 ft- 30 ft. Brown Dirt
30 fL 400 fL Slate
5a.Well Location: ft. ft.
Dan Cole ft. fL
Facility/Owner Name Facility lD#(ifap livable) ft. & Seams:75', 114',269',313'=2g
6212 Olive Branch Rd., Wingate 28174 &6V'(\
rt. rL
Physical Address,City,and Zip L4-(2 21.REMARKS
Union 021990054
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one fat/long is sufficient) /
N W
�-^ 5/10/21
Signature ot'Certltied Well Contractor V Date
6.Is(are)the well(s): (OPermanent or ❑Temporary By signing this farm,1 hereby certrfy than the we//(s)was(were)constructed in accordance
with I5A NCAC 01C.0I00 or i5A N(:AC 02C.0200 well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑NO copy of this record has been provided to the well owner.
Ij this is a repair,f/l out known well construction information and explain the nature of the
repair undera21 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.
For multiple injection or non-water supply wells ONLY with the same a nsrruetion,you can
submit one form SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Par multiple wells list all depths ifd�erew(example-3 200'and 1 a i00') construction to the following:
10.Static water level below top of casing: 45 (ft_) Division of Water Resources,information Processing Unit,
Ifwaterlevel is abm=e casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: iln'addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form F 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 WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 2 Method of test: Air 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.
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Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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