GW1-2021-00836_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:
tt la WATER ZONES
John W. Huneycu
PROM TO DESCRIPTION
Well Contractor Name 115 fL 120 8 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER tf a licable
FROM TO DLUKETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 45 fr 61/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermat closed-too
2 FROM TO DIAMETER THICKNESS MATERIAL
21-20
2.Well Construction Permit#: 2 ft. ft. In.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
fL R. IF
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM ff. TO ft. DIAMETER SLOTSIZE THICKNESS MATERIAL
In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft, in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Lori ation 0 fL 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 ft- Bentonite ! Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage
2 tL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillreck type,grain aim,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 18 iL Brown Dirt
6/23/21 18 fc- 27 ft. Brown Rock
4.Date Well(s)Completed: Well UN fL ft-205 Slate
5a.Well Location: ft. ft.
Jamison Austin ft. ft.
Facility/Owner Name Facility ilN!(ifapplicable) - -
e. rt. Seams: 115'=.8g, 155' ., -
307 Brief Rd E, Midland 28107 ft. ft.
Physical Address,City_and Zip 21.REMARKS
Union 08180006
County Parcel ldentification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: i
(ifwell field,one latAong is sufficient) g��
'',, //N, W. 7/15/21
Si of Certified Well Contractor tl Date
6.Is(are)the well(s): 1OPermanent or ❑Temporary gy,signing this form,1 hereby certify that the well(s)was(nere)constructed in accordance
with 15A NC AC 02C.0100 or 15A NCAC O2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy of this record has been provided to the well owner.
If this is a repair,fill out knmvn well construction information and explain the nature of the
repair under e21 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.
Nor multiple injection or non-water supply wells ONLY with the same construction,you can
submit ane form SUBMITTAL INSTUCITONS
9.Total well depth below land surface: 205 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths tfdiffereni(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (ft.) Division of Water Resources,information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For injection Wells ONLY: In';addition to sending the form to the address in
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
(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.field(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
/2 lb.13b.Disinfection type:
Granular Amount: 1 well construction to the county health department of the county where
constructed. P
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013