GW1-2022-04358_Well Construction - GW1_20220411

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Dwight L. Huneycutt ','" =� �, ' 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 139 ft. 145 ft 4 gpm
4070-A APR 11 202? ft. &
NC Well Contractor Certification Number 4. 15.OUTER CASING for malts-cased wells OR LINER if a licable,
.�.+ 1 FROM TO DIAMETER TffiCIQVFSS AIATERUIL
Derry's Well Drilling Inc. 10e ft 6 v8 in1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
2021-00001119 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. ln•
List all applicable well perndts(.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOTSIZE I TMCKNFBS I MATERIAL
❑Agricultural ❑Mtmicipal/Public f` f` rn
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ll' 3 CL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 IL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tr. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soft/rock tyM grain size eta
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 55 ft. Brown Dirt
6/29/21 55 ft. 95 ft. Brown Granite
4.Date Well(s)Completed: Well il)#
95 ft- 265 ft Blue Granite
Sa.Well Location: ft ft.
Clayton Campbell fL fc
Facility/Owner Name Facility iD#(if applicable)
NCH 42 S, Asheboro 27205 ft. ft. Seams: 112', 115', 139'=4g,240'
ft. R
Physical Address,City,and Zip 21.REMARKS
Randolph 7688594764
Comity Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
N W Df 4VZt-1 rj/a"1L'l.CC.G. 8/15/21
Sibmatum of,ertitied Well Contractor V Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form.I hereby certify that the well(.t)was(rrere)constructed in accordance
with 15A NC4C 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.15 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,Jill am known well construction information and explain the nature of the
repair under r?21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 INSTUCTiONS
9.Total well depth below land surface- 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Nor multiple wells list all depths ifdlierent(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,
Ifvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 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.) F
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.]'raid(gpm)
4 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: 112 lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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