GW1-2022-04362_Well Construction - GW1_20220411

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WELL CONSTRUCTION RECORD For internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor information:
r +" .i "S`• 14.WATER ZONES
Dwight L. Huneycutt a IT !:•'� FROM TO DESCRIPTION
Well Contractor Name APR 1 1 ?n?? 200 ft- 210 ft, 10 gpm
4070-A .._ ft. ft.
NC Well Contractor Certification Number ry F .:.. - 15.OUTER CASiNG for multi-cased vie11s OR LINER if a litable
Ut^.G;:1t:✓:�ilii;i FROM TO DIAMETER THICKNESS MATERIAL
Denys Well Drilling, U\1 is 0 ft. 45 ft 6118 " 1 SDR-21 I PVC
Company Narne 16.INNER CASING OR TUBING thermal dosed-loop)
53967 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(.e.County,Stale,Variance,Injection,etc..)
ft. ft. I is
3.Well Use(check well use): 17 SCREEN
Water Supply well: FROM TO DIAMETER I SLOTSIZE THICKNESS MATERIAL
tn.
❑Agricultural ❑Municipal/Public ft. fL
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. 10
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑firi ation 0 f" 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery
3 ft- 35 Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. NfATERtAL EMPLACIRHENTNIETHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hgPoness,soillreck tyM grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 5 ft. Sand
4.Date Well(s)Completed: 7�26/21 well fD# 5 28 ft. Brown Dirt
28 ft• 225 ft- Blue Rock
5a.Well Location: ft ft
David Boles
ft. fL
Facility/Owner Name Facility to#(if applicable)
ft. ft. Seams: 46-55,72',90',200'=10g
279 Green Rd, Ellerbe 28338 1L ft.
Physical Address,City,and Zip 21.REMARKS
Richmond 744900814017
County Parcel ldentificationNo.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
Orwell field.one latAong is sufficient)
N `,I, t�GLL 8/15/21
Signature Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary fry,signing this form,1 hereby terrify that the well(s)was(were)constructed in accordance
with 15A MAC 02C.0100 or 15A NCAC,02C.0200 Well Conslruclion Standards and that a
7.is this a repair to an existing well: ❑Yes or END copy of this recruit 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 921 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
9.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 INSTUC 110NS
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 lfdii erenl(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 30 (fb) Division of Water Resources,information Processing Unit,
Ifwarer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 011.) 24b.For infection 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 Center,Raleigh,NC 27699-1636
24c.For Water Supply&InjectioniWells:
13a.Yield(gpm) 1 Method of test: Air 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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