GW1-2021-00693_Well Construction - GW1_20211208

V
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.WATER ZONEs
FROM TO DESCRIPTION
Well Contractor Name 212 ft' 215 ft• 5 gpm
4070-A 219 fL 225 fL 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER- TffiQaIESS MATERIAL
Derry's Well Drilling, Inc. 0 ft• 187 ft• 6 1/8 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft
List all applicable well permits(i.e.Countv,Store.Mariance.Injection,etc.) fL ft• in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOTSIZF. THICKNESS MATERIAL
m.Agricultural ❑Municipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
FROM '10 MATERIAL' EMPLACEMENT MVI'HOD&AMOUNT
❑irri atlon 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 fL 35 ft• Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ticable
FROM TO MATERIAL' NiEI'HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
it. tt.
❑Experimental Technology ❑Subsidence Control Ztl.DRILLING LOG'attach additional Sheets if necessary
❑Geothernal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soitimck type.grain sae.etc.
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 16 ft• Red Dirt
4.Date Well(s)Completed: 10/14/21 Well m#Well #5 16 ff• 52 ft• Sandy Brown Dirt
52 ft- 70 ft. Brown Granite
59.Well Location:
Aaron Brown 70 ft- 350 ft' Gray Granite
ft. ft.
Facility/Owner Name Facility ID4(if applicable) ft. ft.
Seams:95',113', 150',212'=5g,219'=5g
6981 Airport Rd., Bear Creek 27207 ft. ft.
Physical Address,City,and Zip
2L REMARKS
Chatham 3843 021
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 R'
il'r't' 11/8/21 a
Signature of ertified Well Contractor Date
6.1s(arc)the well(s): ©Permanent or ❑Temporary
$1'signing this forur,I hereby certjj,tlrut the tee//(s)was/were)constructed in uccorrlonce
u•idt I SA NCAC 02C.0100 or 15A:VCAC 02C.0200 li'ell Construction Standards and thew!a
7.Is this a repair to an existing well: ❑Yes or E!3No copi;ol7his record has been provided it)the ire/1 owner.
I%this iy a repair,i/out known well consiruc•tion inlo nralion and explain the nature o(the
repair under°21 remarks sec/inn or air the hack of this f nrni. 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.
1-or nruhiple injection or non-u•aler supply irells ONLY midi du•.same construction,ynu can
suhndt one foam. SITBMiITAL INSTITC CONS
9.Total well depth below land surface: 350 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far nwhiple irells list all depths i(di(jcrcni(unmple.-3LiL00'and 2 ail00') construction to the following:
10.Static water level below top of casing: 35 (ft.) Division of Water Resources,information Processing Unit,
Ijiraler/eitd is above ceasing.use"-- 1617 Mail Service Center,Raleigh,NC:276994617
11.Borehole diameter: 6 (in.) 24h. For iniection 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 folio"me:
(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 276"-1636
m 13a.1'ietd
(gpm) Method of test:
10 Air 24c.For Water Supply&injection Wells:
Also submit one copy of this form �itbun 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well cunstruc(iun to the eounh• health department of the count),where
constructed.
i
Form GW-I North Carolina Department of En%uonnient and Naunal Resources-Division of Water Resoiaces Revised AuLusl 2013