GW1-2021-00692_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used far single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt F4.WATERZANES
g Y FROM TO DESCRIPTION
Well Contractor Name 292 ft. 300 fL 60 gpm
4070-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable
FROM TO DIAMETER' . TfnCKNESS MATERIAL
Denys Well Drilling, Inc. 0 ft. 77 ft 61/8 hL I SDR-21 PVC
Company Name 16.1NNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(.e.County,State,Variance,Injection,etc.)
CL R. is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
OO Agricultural ❑Municipal/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 & 3 ri- Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 ft• Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cifapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL' EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
It. tt
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if uecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soiltrock tyM grain size,d0
❑Geothermal Heating/Cooling Return ❑Other(explain under#21 Remarks) 0 ft. 36 ft. Wet Brown Dirt
4.Date Wells)Completed: Well no10/15/21 Well #6 36 ft. 62 ft. Brown Granite
62 ft. 325 ft- Gray Granite
Sa.Well Location: ft. ft.
Aaron Brown AL ft.
Facility/Owner Name Facility iDA(if applicable) fr. ft
Seams:82', 115', 138-141', 149', 170', 190'
6981 Airport Rd., Bear Creek 27207 R. f. 235%250',288',292'=Qg
Physical Address,City,and Zip -
21.REMARKS �
Chatham 3843
County Parcel Identification No.(PiN) 90
21
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: L
(if well field,one Iatilong is sufficient) +y I
N w 11/8/21 >ci. !rdi i
Signature of rcrtitied Well Contractor Cl Date
6.Is(are)the well(s): pPermanent or ❑Temporary By signing this farm,1 hereby certify that the well(s)was(ivere)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy rfthis record has been provided to The well in mer.
If this is a repair,fill out known well construction information and explain the nature of the
repair under ii2l remarks section or on the back ofthts 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.
tar multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMri TAL TNSTLICTiONS
9.Total well depth below land surface: 325 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtfferent(example-3@200'and tea 100') construction to the following:
10.Static water level below top of casing: 18 (ft,) Division of Water Resources,information Processing TJnit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 24b.For infection Wells ONLY: 1n addition to sending the form to the address in
Rota 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
13a.Yield m 60 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 lb. 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