GW1-2021-04525_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells C
1.Well Contractor Information:
14.WATER ZONES i
Dwight L. Huneycutt '%EIVED FROM TO DESCRIPTION
Well Contractor Name 195 ft' 202 ft• I 15 gpm
4070-A APR 2 9 2021
NC Well Contractor Certification Number ry OUTER CASING for multi cased wells OR LINER if a licable
IrlScrl..at?on pr"ceySfO J M TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. [)WR Section 0 rL 47 ft 6 1/8 '° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
20-461 FROM TO I DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: tit. tit. �•
List all applicable well permits(i.e.Count•,State,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irrl ation 0 ft' 3 rt• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rt. 35 ft- BentonitePumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licabli
FROM TO MATERIALI EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
tt. ft.
❑Experimental Technology ❑Subsidence Control
10.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hsrdnes soil/rock type,gnin sin,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 14 ft. Brown Dirt
" ft•
4.Date Well 3/8/21 14 225 Slates)Completed: Well ID# tit. ft.
Sa.Well Location: tt. ft.
Donna Brooks ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5221 E Lawyers Rd, Wingate 28174 (Lt1) seams:s�',ss', 195'=15g
tit. ft.
Physical Address,City,and Zip 21.REMARKS
Union 02199006
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one Iat/long is sufficient)
N W
D LtL. 3/25/21
Signature ofCertified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that'the uell(s)it-as(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 I ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No cow of this record has been provided to the umll onwer.
If this is a repair,fill out knonn 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
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 nith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 14 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+ 1617 Mail 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 form within 30 days of completion of well
12.Well construction method: Rotary 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 Center,Raleigh,NC 27699-1636
i '
13s.Yield m 15 Method of test: Air 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form♦within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013