GW1-2021-00696_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fort can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt FR WATER ZONES
ROM TO DESCRIPTION
Well Contractor Name 230 ft. 235 ft. 30 gpm
4070-A ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft 90 ft 61/8 o- I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Parcel # 3843 FROM TO DIAMETER THICIINFSS MATERIAL
2.Well Construction Permit#: ft. R. in
Last all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
iL ft in.
RlAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. It. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fro. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 35 it. Bentonite Pumped
Injection Well: M ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
ft. ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sail/rock type,grain etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 25 ft. Red Dirt
4.Date well(s)Completed: 9/3/21 well ID# Well # 2 25 ft. 68 It. Brown Sandy Dirt
68 ft. 82 ft. Brown Granite
5a.Well Location: 82 350 ft. Gray Granite
Aaron Brown ft. IL
Facility/Owner Name Facility ID#(ifapplieable) g, ft. Seams: 130', 136', 149', 149', 172',
6981 Airport Rd., Bear Creek 27207 ft. ft
207',230'=309
Physical Address,City,and Zip
21.REMARKS
Chatham 3843
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) /
N W 7�G1x Lt".L. 9/30/21:, i
Signature of &fified Well Contractor V +Date
6.Is(are)the well(s): 1271'ermanent or ❑Temporary By signing this form,I hereby certify that;the well(s)was(were)constructed in accordance
with 1 SA 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 EINo copy ofthis 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 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 same construedon,you can
submit one form. SUBMITTAL INSTUCfIONS
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 ij'different(example-3@200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: 41 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use..+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniegtion 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method oftest: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form 1,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.
I
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013