GW1-2022-04360_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. Huneycutt ,, ��.,,;�- , Tz:F
WATERZONES
S� -,..*b DESCRIPTION
Well Contactor Name ft 50 gpm
4070-A A�Q 11 2022 ft
NC Well Contractor Certification Number 15.OUTER
CA NG for multi-cased wells O cable
FROM T DIAMTER R MAT ERIAL
Derry's Well Drilling, Inc. io ft 26 ft 61/8 in1 SDR-21 I PVC
Company Name t 16.INNER CASING OR TUBING thermal dosed-loop)
322464 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft. ft. im
❑Agricultural ❑Municipal/Public
h.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 3 IL Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it- 20 ft- BentonitePumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Crroundwater Remediation 19.SAND/GRAVEL PACK f applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DATERIAL EMPI.ACEMENTAIETHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage
It. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheen;if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardnes%soNrock type, in size,etc
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 11 rL Sand and Cobble Stones
7/9/21 11 ft- 145 ft- Blue Granite
4.Date Well(s)Completed: Well am
ft. ft
5a.Well Location: ft. ft.
Gladys Whittaker IL h,
Facility/Owner Name Facility iD#(ifapplicable) ft. ft. Seams: 101', 113', 135'=50g
270 Sneeds Mill Rd, Rockingham 28379 ft. &
Physical Address,City,and Zip 21 REMARKS
Richmond 745100367005
Comity Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iatflono is sufficient)
N N Lt`,L.. 7/25/21
Signature of-ertitied Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By,signing this fornr,1 hereby certify that the well(i)was(were)constructed in accordance
with 1 SA N(.AC 02C.0100 or 15A MAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ❑No copy ofthis record hav been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature c f the
repair under r21 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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
F'or 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: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifJereni(example-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: 16 (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For infection Wells ONLY: in addition to sending the form to the address in
Rotary 24a above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.]'field(gpm) 50 Method of test: Air
24c.For Water Supply&Injection]yells:
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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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