GW1-2023-01631_Well Construction - GW1_20230214

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Der L. Huneycutt 14.WATERZONEs 1 .�
Derry Y FROM TO DESCRIPTION!
Well Contractor Name - q Z f_ 250 ft' 255 ff P I 3 9pm
2663-A ��^: ��- ; '0 �.,n, ft %
NC Well Contractor Certification Number _�j 15.OUTER CASING for multi-cased wells OR LINER if a licable
FEB 1 N. 2 FROM . TO DIAMETER : THIC[INESS nL►TERrAL
Derry's Well Drilling, Inc. 0 ft 50 ft- s 1/8 ; 1 SDR-21 I PVC
Company Name Irlii i n u �� + 3'�;F. 1�n:1 16.INNER CASING OR TUBING(geothermal closed-loop)
22-308 D<`ti '� FROM TO . DIAMETER' THICENM 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 :SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in ;i
❑IndustriaU 18.GROUTCommercial ❑Residential Water Supply(shared) FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 R•. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 ft. Bentonite Pumped
Injection Well: ft ft.
v .
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL'; , EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I'
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional'sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rack a etc.)
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft Brown Dirt
8/31/22 10 fL 300 ft ! Blue Rock
4.Date Well(s)Completed: We11.ID# ft ft
Sa.Well Location: ft. ft
Jerry Brent Collins ft rt
Facility/Owner Name Facility ID#(if applicable) p
171'9 Austin Chaney Rd, Wingate 28174 ft ft. Seams,:1,15', 130',145', 167',189',210',.
225',234,250-255'=3gpm
Physical Address,City,and Zip .21.REMARKS
Union 09043004
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) �'
9/30/22
/ 1
Signature of ed Well Contractor �' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the;wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 6C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy ofthis record has beenprovided to theirvell 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:
may
ay 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 I;
submit one form. SUBMITTAL INSTUCI•IONS
L9.Total well depth below land surface: 300 (ft,) 24a. For All Wells: Submit this within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 2@100) construction to the following:
40 Division of Water Resources,Information Processing Unit,
10.5tatic water level below top of casing: (ft) rc
1617,Mail Service Center`,Raleigh,Ifwater level is above casing:use"+" I ig ,NC 27699-1617
11.Borehole diameter: I) (in.) 24b.For Infection Wells ONLY: h,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:
(Le.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(-,pm) 3 Method oftest: 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013