GW1-2021-04470_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Wen Contractor Information:
Dwight L. Huneycutt �`� ��\ FR WATER ZONES
ROM TO DESCRD''ITONr
Well ContractorNante 04 440 n 450 n 6 gpm
4070-A PQ� �toLe o\
$ 15.OUTER CASING for mutes-eased wells OR LINER a Ileable
NC Well Contractor Certification Number 3,`O��� FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. sock' O� 0 162 n 6 1/8 1in SDR-21 PVC
Company Narne 16.INNER CASING OR TUBING(geothermal closed-loop)
2020-00001398 FROM TO DL"IETER Tmclawss MATERIAL
2,Well Construction Permit#: n• n• iO•
List all applicable ivell permits(i.e.County,State,Variance,Injection,ate.) n ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: FROM TO MACE�•R SLOT SITE TH OOMS NATERIAL
n. n. In.
QA.gricultural ❑Municipal/Public
QGeothetmal(Heating/Cooling Supply) AJRcsidential Water Supply(single) n t► In.
QlndustriaUCommercial QResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Qlmi ation 0 n. 3 n• Bent.Chips Gravity
Non-Water Supply Well:
QMonitoring QRecov 3 n 20 n Bentonite Pumped
Injection Well:
❑Aquifer Recharge QGroundwater Remcdiation 19.SAND/GRAVEL PACK If applicable)
FROM TO AATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery QSalinity Barrier n. rt.
QAquifer Test QStormwater Drainage n.
DExperimental Technology QSubsidenec Control
20.DRILLING LOG attach addltlonal'sheets If necessary)
QGeothermal(Closed Loop) QTraeer FROM TO DESCRIMON color,hardnes.%sowrock t37e,grain size,etc
QGcothemtat (Heating/Cooling Return QOther(explain under#21 Remarks 0 n. 37 n• Brown Dirt
4.Date Well(s)Completed: 1 1/17/20 Well>D# 37 n 50 ft.
Brown Granite
52 n 545 n Blue Granite
5a.Well Location:
Dylon Chriscoe
Facility/Owner Name Facility ID'c(if applicable)
6102 Union Grove Church Rd., Seagrove 27341 Seams: 74',8s', 155',44o'=6g
Physical Address,City,and Zip 11.REMARKS
Randolph 7695062876
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Cerdfleadon:
(if well field,one ladlong is sufficient) �`^J4 •- /1,� „(�
N W Y r 12/9/20
Signature of Certified Well Contractor Date
6.Is(are)the well(s): EdPermanent or ❑Temporary
11y signing this form,I hereby cerrify that the tvell(s)wos(lucre)constructed in accordance
idth 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Consmictlon Standards and that a
7.Is this a repair to an eidsting well: ❑Yes or ®No copy ojthis record has been provided to the it-ell owner.
1f 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 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 construe": 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: 545 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-9@200'and 2@100) construction to the following:
10.Static water level below top of casing; 25 (ft,) Division of Water Resources,Information Processing Unit,
Iftvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of thus form within 30 days of completion of well
12.Well coustruction 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 Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 6 Method of test• Air 24c.For Water Supply&Infection Wells:
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.
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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