GW1-2023-02641_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
g Y FROM TO I DESCRIPTION
Well Contractor Name 212 ft- 218 ff• 3 gpm
4070-A _ fL ft-
v "~r 15.OUTER CASING for multi-cased wells OR LINER if a licable
NC Well Contractor Certification Number t•.:,, d
y FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR t ,,,,,,, 0 fl 45 ft
61/8 is I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22-258 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: := I t ..,•. fL ft. in
List all applicable well permits(i.e.County,State,Variance,Injec116d,' tcJ y
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL fL ia.
❑Agricultural ❑Mtmicipal/Public
❑Geothermal(Heating/Cooling Supply) E IResidential Water Supply(single) ff• & in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 it. Bent.Chips Gravity
Non-Water Supply Well:
3 fL 20 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO (MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tl fr.
❑Aquifer Test ❑Storrnwater Drainage
ft. ft.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soi0rock type.grain sizq etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 M Red Dirt
4.Date Well(s)Completed: 12/27/22 Well ID# 5 ft 25 ft. Brown Dirt
25 ff• 33 ft. Brown Rock
5a.Well Location: 33 fl 325 ft Slate
Purvi Patel fL ft.
Facility/Owner Name Facility ID#(ifapplicable)
5229 E. Lawyers Rd, Wingate 28174 ft. ft.f Seams:69',74', 135',212'=3gpm
Physical Address,City,and Zip 21.REMARKS
Union 02-199-006B
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)
N W TJc Lt.�. aa►1.¢r�j cd 1115/23
Signature orCertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify 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: ❑Yes or BNo copy ofthis record has been provided to the well owner.
If[his is a repair,fill out known well construction information and explain the nature ofthe
repair under#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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-watersupply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-3ca 200'and 2Q100) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injjection Wells:
Also submit one copy of this form within 30 days of completion of
136.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