GW1--02772_Well Construction - GW1_20240507

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
9 Y FROM TO DESCRIPTION
Well Contractor Name •._' R ""''3 F 321 fL 325 ft' I I 2 gpm
4070-A S : �' @e,Lx 338 ft• 342 ft I ! 2 gpm
NC Well Contractor Certification Number
MAY v J f; A 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
L G24 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. hs,:.,..,:,.., ,,.__{ o ft 62 tt 61/8 ', in- SDR-21 Pvc
Company Name Gii;,'(+•s ;;,-.` JPZtt 16.INNER CASING OR TUBING(geothermal closed-loop)
r <_k:] FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 24-34 ft. ft. in.
List all applicable well permits(.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) OResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT
ft. ft.
❑Aquifer Test ❑Stormwater Drainage •
ft. ft.
❑Experimental Technology ❑Subsidence Control •
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 38 ft Brown Dirt
4/2/24 38 ft 365 ft Slate
4.Date Wells)Completed: Well ID# ,
ft. ft.
5a.Well Location: ft. k, ft. i.
Jeffery Muska(Brooke Hickson) -
rt. ft Seams:69',75',83',94', 114', 168',214',
FacilitylOwner Name Facility ITV(if applicable) ft. ft. 256,297,310,315,321=2g,334,
5125 White Store Rd, Wingate 28174 n, ft. .
Physical Address,City,and Zip 338_`2g
21.REMARKS
Union 02-226-008D
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 W z7GL � 4/16/24
Signature of citified Well Contractor Date
6.Is(are)the well(s): I27Permanent or OTemporary By signing this farm,I hereby certifr that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I lNo 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 remark section or on the back of this fornx 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 I
9.Total well depth below land surface: 365 (ft.) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3®200'and 2Q100) construction to the following: I.
10.Static water level below top of casing: 30 (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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water ResourcesjUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Injection 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