GW1-2022-04357_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:
W
John W. Huneycutt
FROM ATER ZO TONES DEScau,,noN
Well Contractor Name 87 ft- 90 ft. 3 gpm
APR 11 2022
2465-A 130 IL 135 it. 4 gpm
15.OUTER CASING for d ells)?y ...Riifapqicable)
DIAMETER
NC Well Contractor Certification Number It T�=
'k FROM TO TVA.Ne MATERIAL
0 160 It" 16 1/8 SDR-21 PVC
Derry's Well Drilling,
Company Name 16.INNER CASING OR TUBING(geother al closed-loop)
2.Well Construction Permit#: 2021-00002914 FROM ft. TO I DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County,State,Variance,Injection etc.) ft- I
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal/Public ft It. in.
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft. in.
DlndustriaUCommercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&_AMOUNT
ObTigation 0 fL 3 rt. Bent.Chips Gravity
Non-Water Supply Well: 3 ft 35 fL Bentonite Pumped
ElMonitoring ORecovery
Injection Well: ft. ft.
DAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK01'applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinity Barrier ft. It.
E]Aquifer Test ElStormwater Drainage ft. ft.
ClExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if nece I ssary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,saflImck type,grain she,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 13 ft Brown Dirt
4.Date Well(s)Completed: 1/11/22 Well 11D# 13 ft- 30 ft. Brown Rock
30 ft- 225 IL Blue Rock
5a.Well Location: % ft.
Roy L. Robinson Jr. ft ft.
Facility/Owner Name Facility ID#(if applicable) ft. & Seams: 73',87'=3g,95% 107', 11 6=3g,
1139 Iron Mtn View Rd., Asheboro 27205 ft. ft. 130'=1g
Physical Address,City,and Zip 21.REMARKS
Randolph 7780685301
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)N W ge4r' 66) 1/25/22
Si of Certified Well Contractor C/ Date
6.1s(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby cerl that;the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or END copy of this 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: 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 INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jdifferent(example.3@200'and 2@100') construction to the following:
10.Static water level below top of casing, 30 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in-) 24b.For Jaiection 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.e.auger,rotary,cable,direct push,etc-) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Cen I ter,Raleigh,NC 27699-1636
: I
13a.Yield(gpm) 7 Method of test: Air — 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I 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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013