GW1-2022-04345_Well Construction - GW1_20220411

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Hunecuff r" e ;7a„ 14.WATER ZONES
7 �T7 q , t ,7 j ) FROM TO DESCRIPTION
Well Contractor Name 68 ft 75 ft 20 gpm
4070-A APR 11 2022 ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi cased wells OR LINER if a livable
G`iFN�,, t,{1a`F1.ri1 FROM TO DIAMETER THIC[INFSS MAT17t1AL
Derry's Well Drilling, Inc. 47 ft- 61/8 ' in SDR-21 PVC
Company Name r 16.INNER CASING OR TUBING thermal closed-loop)
350622 FROM To DIAMETER THICKNESS MATERIAL
2.Well Construction Permit t}: ft. TO
In.
List all applicable well permits(11.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
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft' in
❑industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
❑trri ation 0 tt 3 tL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 rL 35 ft. Bentonite Pumped
injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa icable
❑Aquifer and Recovery Storage FROM TO MATERIAL, EMPLACEMENT'METHOD
4 ❑Salinity Barrier 2 ir.
❑Aquifer Test ❑Stormwater Drainage
8. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,sail/mck tym grain etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft 9 ft White Sand
7/29/21 9 ft 15 ft White Clay
4.Date Well(s)Completed: Well LI?li
15 ft. 29 ft Brown Dirt
5a.Well Location: 29 ft• 100 ft• Blue Granite
Christopher Holt ft rt
Facility/Owner Name Facility ID#(if applicable)
Pine Forest Rd, Cameron 28326 ft. f` Seams: 55,68'=tog
ft fr.
Physical Address,City,and Zip
21.REMIARKS
Lee
Comity Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one Iat/long is sufficient)
N W, ��,�., 8/15/21
Signature d C etified Well Contractor Date
6.is(are)the well(s): (OPermanent or ❑Temporary Hy signing this form,/hereby certify that the wel/(v)was(were)consiructed in at ardance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E3No copy afrhis record has been provided to the well mvner.
Ifthis is a repair,fill out known well conviruetion information and explain the nature of the
repair under r21 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 construction,you can
submit one farm SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 100 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdljferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 28 (ry) Division of Water Resources,information Processing Unit,
Ifwaterlevel is 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
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
132.Yield(gpm) 20 Method of test: Air
24c.For Water Supply&Injection GWe E
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. j
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013