GW1--05044_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells I
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES "
FROM TO DESCRIPTION
It ft gp
Well Contractor Name FS •.— a.,, 11 . �q 192 200 7 m
4070-A `4"-�J i V E? ) ft. ft. I '
NC Well Contractor Certification Number nnf' +++��� 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
/-)UG 6 2U23 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 56 ft. 6 1/8 , in- SDR-21 PVC
Company Name
lt{ila:I`,-c ,:t%S1 Pr.^.p y y„ i 16.INNER CASING OR TUBING(geothermal closed-loop)
21-41 D'�'�` �� •'V li51 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Counry,Slate,Variance,Injection,etc.) ft. ft. In
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 D• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft• 20 ftBentonite Pumped
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 ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sot Frock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 31 ft. Brown Dirt
4.Date Well(s)Completed: 7/7/23 Well D�1 31 it 48 ft- Brown Rock
48 ft. 265 ft• Slate
5a,Well Location: ft. ft.
Union Homes, LLC ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1620 McIntyre Rd,Wingate 28.174(McIntyre Est., Lot 8) ft. ft" Seams:89-95',97-102', 169', 192'=7gpm
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 09009002K
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient)
N ,l, Z)Gli � a..47.6d-t. 7/21/23
Signature o ertified 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 1SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record 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#21 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
8.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
For multiple wells list all depths ii different(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing; 40 (ft,) Division of Water Resources,Information Processing Unit,
If water 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
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 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: 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