GW1-2021-04527_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES 1 I
g Y44 FROM TO DESCRIPTION
Well Contractor Name 218 rL 225 rL I 4 gpm
4070-A ft. ft.
NC Well Contractor Certification Number APR 2 9 2021 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER! THICKNESS MATERIAL
Derry's Well Drilling, Inc. rnt ESSIng Uri t0 rL 55 ft- 6 1/8 '° SDR-21 PVC
Company Name ftJ;j1Ii t�'pPGect10fl 16.INNER CASING ORTUBING(geothermal closed-loop)
19-135 D%tVR J FROM TO DIAMETER i THICKNESS MATERIAL
2.Well Construction Permit#: !°•
List all applicable well permits(i.e.County,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
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. 1° i
❑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:
❑Monitoring ❑Recovery 3 rt. 35 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIALS 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 type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt' 12 e' Brown Dirt
3/11/21 12 rt' 25 rr• Brown Rock
4.Date Well(s)Completed: Well ID#
25 ft- 365 It- Slate
5a.Well Location: ft. ft.
Sarah Clontz rL it.
Facility/Owner Name Facility 1134(if applicable) ft. ft.
Seams: 85',92',218'=4g
Old Dutch Rd. W, Indian Trail 28079 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 08183008 j
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one]at/long is sufficient)
N W DZ— y 4/7/21
Signature of Certified Well Contractor Date
6.Is(are)the well(S): ©Permanent or ❑Temporary By signing this form,I hereby cert ,that'the uell(s),ras(were)constructed in accordance
oath 15.4 NCAC 02C.0100 or 1 SA NCAC 02C.0200 11'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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 walh the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
i
34 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this ft 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 Ceti ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c•For Water Supply&Injection Wells:
Also submit one copy of this formil 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.
i
Form GW-1 North Carolina Department of Emaronment and Natural Resources—Division of Water Resources Revised August 2013
i
i