GW1-2021-01781_Well Construction - GW1_20210429

i
WELL CONSTRUCTION RECORD s For Internal Use ONLY: R
This form can be used for single or multiple wells
1.Well Contractor Information: 14.
�)
Dwight L. Huneycutt v O FR MATER ZONES TO DESCRIPTION
Well Contractor Name �g 212 ft. 215 tt 1 gpm
4070-A PQ t\QtCGe �n 276 rt. 285 ft. 2 gpm .
NC Well Contractor Certification Number �Sg 15.OUTER CASING for multi cased wells OR LINER if a licable
c �p`� FROM TO DIAMETER: THICKNESS MATERIAL
Derry's Well Drilling, Inc. ���� 0 ft' 52 fL 61/8 'in• I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2018011W(NC Variance#WWM785) FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. Iiu
List all applicable well permils(i.e.Count),,State,Variance,Injection,etc.) �.
ft. ft. tu.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER iSLOTSIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
f B• in.
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPPIY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 rL 52 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑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 soil/rock a in size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft• 23 ft• Red Clay
10/27/20 23 B 45 ft• Brown Rock
4.Date Well(s)Completed: Well ID#
45 ft• 500 ft Slate
5a.Well Location:
Les Murray/Steven&Cynthia King
Facility/Owner Name Facility ID#(if applicable)
ft-175 Mountain View Ln, Troy 27371 ft• • Seams:;so',ss',73', 130', 135', 167', 1sa,
Y e. ft. 212'=1g,276'=2g
Physical Address,City,and Zip 21.REMARKS
Montgomery 6588-14-22-9577
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 11/18/20
Signature ofCcrtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cerfif,that jthe well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENO copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out knonw hell construction information and explain the nature of the i
repair under#21 remarks section or on the back ofthis 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3e200'and 2@a,100') construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use••+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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: j
(i.e.auger,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
t
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) 3 Method of test: Alt '
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 1/2 lb.Granular well construction to the county heal th'department of the county where
constructed. €
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
II
I �