GW1-2021-04473_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fonu can be used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt 14.WATER ZONES
FROM I TO DESCRIPTION'
Well Contractor Name Wle
252 n 260 n 10 gpm
2663-A PQ�-y Gesspq
NC Well Contractor Certification Number Q(Q vfl� I&OUTER CASING for multi-cased wells)OR LINER f a flcable
� �CJQ,.V`' FROM n. TO n. DL4WTERitn. THICKNESS MATERIAL
Derry's Well Drilling, Inc. ��• ��1 0 62 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
202Q-QQQQ1722 FROM TO DIAMETER THICKNESS DfATERIA[
2.Well Construction Permit#: n, n. in.
List all applicable well permirs/i.e.County,State,Variance,Injection,ate.)
n. n. m.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMTER SLOT SITE THICKNESS MATERIAL
❑Agricultural QMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single)
❑lndustrlal/Commercial ❑Residrntial Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD lk AMOUNT
❑hri ation 0 n' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Rcoov 3 n 20 n Bentonite Pumped
Injection Well:
QAquifer Recharge []Groundwater Remcdiation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL' I EMPLACEMENT METHOD
El Aquifer Storage and Recovery ❑Salinity Burner
n. n.
OAquifer 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,hardn soil/rock type,strata size,etc
❑Geothermal catin Coolie Rctum []Other(explain under#21 Remarks 0 n 13 n Brown Dirt
4.Date Weff(s)Completed: 12/19/20 Well ID# 13 n 41 n Brown Dirt and Rock
41 n 285 n' Blue Rock
Sim.Well Location:
Victoria Ayala
Facility/OwnerNarue Facility M#(ifapplicable) n. n. Seams: 89', 116',187',206',252'=10g
5632 Davis Country Rd., Randleman 27317
Physical Address,City,and Zip 21.REMARKS
Randolph 7756372341
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cerdflcadon:
(if well field,one lattlong is sufficient)
N W
�GtJZ¢t7i - 1/15/21
Signature ofOVaified Well Contractor Date
6.Is(are)the wefl(s): f2lPermanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
wills 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this 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 flit 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 tvirh the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 fft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(axample-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 17 (g,) Division of Water Resources,Information Processing Unit,
If uwter level is above casing,use"+" 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
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 j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 10 Method of test: Air 24c.For Water Supply&Injection 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.
Form OW-t North Carolina Department of Environment and Natural Resources—Division of Water Res I oluves Revised August 2013
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