GW1-2021-04509_Well Construction - GW1_20210429

I
i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
1 a 14.WATER ZONES
Dwight L. Huneycutt t�G % FROM TO DESCRIPTION
Well Contractor Name 270 ft' 280 n• I 39pm
4070-A pNR �+ 9 2021 ft. rt.
15.OUTER CASING for multi-cased wells OR LINER f o Ilcable
NC WellContrnctorCerificetionNumber r�;,',,Ss (3, FROM TO DL41111TER THtCI.AESS DIAIERIAL
Derry's Well Drilling, Inc. JrJGV!"3�� R Sep,°n 0 " 50 R 6 M I" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed400
20-488 FROM TO DIAMETER TmCkNEss MATERIAL
2.Well Construction Permit#: h• n• I"
List all applicable well permits(i.e.Cona)v,State,Variance,Injection,etc.)
ft. R. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICICSTSS 1%1ATERIAL
ft. it. In.
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) R• R• in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 h• 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recov 3 n 35 n Bentonite Pumped
Injecdon Well: n n
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT T METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necasan'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnes soil/rock type,grain size etc
❑Geothemtal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 n' 27 h' Brown Dirt
4.Date Well(s)Completed: 12/21/20 Well ID# 27 n 35 n Brown Rock
35 B 365 n Slate
Sa.Well Location:
Austin Hills, LLC n n
Facility/Owner Name Facility ID#(if applicable)
2314 Louanne Dr., Wingate 28174 (Austin Hills Lt 37) Seams: 56', 136',27o'=3g
Physical Address,City,and Zip 21 REDIARKS
Union 02-199-058
Comity Parcel Identification No.(PIN)
.5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cerdfleadon:
(if well field,one lat/long is sufficient)
�G � GlJ2Q�,�N W 1/15/21
Signature ofCerified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
13y signing this form,1 herein c¢rtify that the well(s)was(yes&)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 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.
For multiple injection or non-warer supply wells ONLI'tvith the same construction,you can
submit one form. SUBI%f rrAL INSTUCTIONS
9.Total well depth below land surface: 888 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Ceniter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: hi addition to sending the form to the address in
Rotary 24a above, also submit a copy of this!font 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 Mail Service Ceiter,Raleigh,NC 27699-1636
13s.Yield(gam) 3 Method of test: 'Air 24c.For Water Supply&Infection Welts:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county heal h!department of the county where
constructed.
Form GW-1 North Carolina Department of Enviromnew and Natural Resources—Division of Water Resources Revised August 2013