GW1-2021-04471_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: �v` 1�
John W. Huneycutt op ` 14.WATER ZONES M TO DESCRIPTION
Well Contractor Name Q, 265 n 270 n ( 9gpm
2465-A Q�ti Qs�e�yoo n. n.
NC Well Contractor Certification Number Qt ( 15.OUTER CASING for multi-eased wells OR LINER a Icable
5e FROM TO DIADtE7'ER TMCK S MATERIAL
Derry's Well Drilling, Inc. �'���1� p n 78 n 6 1/8 !in' SDR-21 I PVC
Comynany Name r 16.INNER CASING OR TUBING eothermal closed-loop)
2Q1$^QQQQ1 19 FROM TO DIA11MM 7'MMTSS MATERIAL
2.Well Construction Permit#: n. n. ,la.
List all applicable well permits(i.e.County,State,Variance,Injection,atc.)
n. n. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n• n• 1n.
❑Geothermal(11cating/Cooling Supply) ❑Residential Water Supply(single) n. n. In• f
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO DATERIAL EMPLACEMENT METHOD&ANIOUNT
01ni ation 0 n• 3 n• Bent.Chips Gravity
Non-Water Supply Well;
3 n 20 n Bentonite Pumped
❑Monitoring ❑boy
Injection Well:
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAVEL PACK 1l a llcable
FROM TO MATERIAL EMPLACENUM METHOD
❑Aquifer Storage and Recovery ❑Salh»ty Barrier n n.
❑Aquifer Test ❑Stormwater Drainage
n. n.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,bardn solltrwit type,grain size eta
❑Geothermal catin Coolie Return ❑Outer(explain under#21 Rcmarks 0 n 39 n Brown Dirt
12/22/2U 39 n 58 ft.
Brown Rock
4.Date Well(s)Completed: Well ID#
58 n 305 n Blue Granite
So.Well Location:
John & Karen Bloxsom
Facility/Owner Name Facility ID#(if applicable) n, n• Seams: 119', 165',254',265'=9g
6307 Farmer Denton Rd., Denton 22239 n. n
Physical Address,City,and Zip 21.REMARKS
Randolph 6699664330
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/mloutes/seconds or decimal degrees: 22.Cc cation:
(if well field,ate lat/loug is sufficient) J
1/20/21 N `,it
SignatWe of Certified Well Contractor Date
6.Is(are)the well(s): [dFermanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
Milt 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an esisdng well. ❑Yes or ONo copy of this record has been provided to the'well owner.
If this is a repair,fill out known wall construction information and orplain 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 with the seine construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 306 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list an depths if diA'eront(example-3@200'and 2@1001 construction to the following: i
10.Static water level below top of casing: 18 (it,) Division of Water Resources,Information Processing Unit,
If tt,ater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For Inlertlon Wells ONLY: in.addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
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&Iniectiou 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.
From O W-1 North Carolina Deparmtent of Environment and Natural Resources-Division of Water Resources Revised August 2013
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