GW1-2022-04356_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:
' 14.WATER ZONES
Dwight L. Huneycutt -; :i:--
a a M ' FROM TO DESCRIPTION
Well Contractor Name 292 it 298 f' 100 gpm
4070-A p P R 11 202'- ft. ft.
NC Well Contractor Certification Number 15.OUTF.R CASING for multi cased wells OR LINER if a livable
tv�,,., . 1,.:�'a�.' FROM TO DIAMETER.' THIC[�IESS MATERIAL
Derry's Well Drilling, Inc. ;�r . 0 fL 46 ft 6 1/8 '- 1 SDR-21 I PVC
Company Name ^`^ 5 16.INNER CASING OR TUBING(geothermal dosed-loop)
2016-00001730 FROM TO DIAMETER: THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIG4ESS MATERIAL
fL in.
❑Agricultural ❑MunicipaUPublic ft
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) It. (L ra
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 n• 3 fL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 fL Bentonite Pumped
Injection Well: ft. f
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
f4 fL
❑Experimental Technology ❑Subsidence Control
10.DRILLING LOG attach additional sheets if necrssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION plot hardness saiVrock type,grain si em)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 4 R• Red Clay
12/28/21 4 rL 21 fL Brown Dirt
4.Date Well(s)Completed: Well ID#
21 fL 300 fL Gray Granite
Sa.Well Location: M It
David Scott Phagan fL ft.
Facility/Owner Name Facility ID#(if applicable)
Cortez Rd., Asheboro 27205 fL fL Seams: 72',90', 116', 149', 155',252',268'
ft. ft i272-276',288',292'=100g
Physical Address,City,and Zip 21.REMARKS
Randolph 7649168339
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W ��.C.. 1/25/22
Signature ofrertified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo 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 ofihisform. 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 form. SUBMITTAL INSTUMONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 Construction to the following:
10.Static water level below top of casing:
9 Division of Water Resources,Information Processing Unit,Ifwater level is above casing,use"+" (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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
13a.Yield(gpm) 100 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 department of the county where
constructed.
i
Form GW-I North Carolina Department of Environmeut and Natural Resources—Division of Water Resources Revised August 2013