GW1-2021-00756_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt FR.WATER ZONES
FROM TO DESCRIPTIONV
Well Contractor Name 250 fL 260 fL 8 gpm
4070-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mullacased wells OR LINER ff s Iicable
FROM TO DIAMETER THICIflVPSS MATERIAL
Derry's Well Drilling, Inc. 0 fL 45 ft- 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eotherrnat closed-loop)
2021-00000855 FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: ft. e. In.
List all applicable well permits(I.e.County State,Variance,Injection,etc.)
ft. I ft. in•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
OAgriculmral ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 tt 35 fc Bentonite .; Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM I TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
f4 ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,saillrock type,grain sae,Hp
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 fL 25 ft. Wet Brown Clay
4.Date Well(s)Completed: 7/1/21 Well ID 4 25 fL 37 ft. Brown Dirt
37 fL 300 ft- Blue Granite
5a.Well Location: fL ft.
Kyle Gillispie fL fL
Facility/Owner Name Facility iD#(if applicable)
4654 Happy Hollow Rd, Asheboro 27205 ft. ft fr. tL Seams:95', 115', , 172,
250'=8g
Physical Address,City,and Zip 21.RF.MARKs
Randolph 7666676078
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W
7/25/21
Signature of'Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the ivell(s)was 6rere)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 ❑No copy,ofthis record has been provided to the wirll owner.
Ifthis 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 farm. 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 construcdon,you can
submit one form SUBMITTAL TNSTUCTiONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdWerent(example-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water Resources,information Processing Unit,
Ifwater level iv 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 I'fottrl 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) 8 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,deptutment of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013