GW1-2022-04366_Well Construction - GW1_20220411

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.WATERZONEs -i
z^j .'„ 'j j�_t...,�� f FROM TO DESCRIPTION
Well Contractor Name T 90 IL 94 ft 40 gpm
4070-A A p R 1, 1 Z02? ft. ft
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cased wells OR LINER if a livable
..,`1` FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. U' ;: �' TPS:y;i l�l u o ft 45 D- 61/8 is SDR-21 PVC
Company Name "�''„ I 16.INNER CASING OR TUBING(geothermal closed-loop)
307095 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft iu.
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 ❑MunicipaUPublic ft IL in.
❑Geothermal(Heating/Cooling✓Coolin Supply) OResidential Water SuPPIY(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ini ation 0 ft• 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 35 fr. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a bitable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To ft MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if neceasa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,mil/rock IyM grain diz,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 18 rt Wet Brown Clay
12/21/21 18 rt 145 ft Slate
4.Date Well(s)Completed: Well ID# ft ft.
5a.Well Location: ft. ft
Jeffery Trexler/Aaron Trexler ft ft.
Facility/Owner Name Facility ID#(ifapplicable) ft ft. Seams: 52',68',75•,90-94'=40g
11675 Stokes Ferry Rd., Gold Hill 28071 ft ft
Physical Address,City,and Zip 21.REMARKS
Rowan 570 025
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifweD field,one tat/long is sufficient) / 1�
N �y �GLt,L GGh4�y 1/10/22
Signature £Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify than the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
Ifthis 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: 145 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tjdiJferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 18 (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 Infection 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) 40 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013