GW1--05057_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
TER ZONES
John W. Huneycutt FRM" TO DESCRIPTION
Well Contractor Name 112 ft. 117 ft- 6 gpm
2465-A 246 ft 290 ft. 2 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 48 ft 6 1/8 i°' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
24-62 FROM TO DIAMETER THICKNESS MATERIAL —
2.Well Construction Permit#: ft. ft. in.
Lest all applicable well permits(i.e.County,State,Variance,Injection,etc.) '— —
fL 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
in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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: R. ft.
I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
i FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage ft fr. -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 25 ft* Brown Dirt
7/11/24 25 ft• 305 ft Slate
4,Date Well(s)Completed: Well ID# fL ft.
5a.Well Location: fL ft.
Brian Benton/Emerald Pointe Realty
ft ft. Seams:56',76',87-95', 100', 112'=6g,
Facility/Owner Name Facility 1134(if applicable)
ft
ft ft. 125', '130', 155', 161', 170',246-290'=2g
5405 E. Lawyers Rd., Wingate 28174
Physical Address,City,and Zip 21.REMARKS ` s +
Union 02-199-006Q `rr.• ` - .
County Parcel Identification No.(PIN) AUG c' .3J 624
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) I Ir.'.�` r f
N W /wt/' A`l5/2.41'
Sign of Certified Well Contractor Date
6.Is(are)the well(s): 2IPertnanent or DTemporary Ity signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0/00 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RiNo 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 remarkr 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 constemedort.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft-)
If water level is above casing,use"'" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
8 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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 OW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013