GW1-2022-04367_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:
John W. Huneycutt 14.WATER ZONES I
:1,,, A FROM TO DESCRIPTION
Well Contractor Name `�;� ~'_) 95 k 100 ft f 40 gpm
2465-A fL ft.
NC Well Contractor Certification Number
�G IS.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER TFDCIflVFSS MATERIAL
Derry's Well Drilling, Inc. '{`'''. a±'` o ft' 85 s vs SDR-21 PVC
., G
Company Name , u—o i" ` to.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit tl: 316933` ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL I f4 m•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. It. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in
❑industriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fir' 3 n• Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 fL Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ft.TO MATERIAL. I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additionalsbeets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION eolor,hardness soillrock type,grain simr,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 21 ft. Brown Dirt
12/10/21 21 ft 67 fL Brown Rock
4.Date Well(s)Completed: Well ID#
67 fL 105 ft. Blue Rock
5a.Well Location: ft ft
Jonathan King ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Seams: 95'=40g
360 Country Ridge Rd., Rockwell 28138 ft fL
Physical Address,City,and Zip 21 REMARKS
Rowan 435 048
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iat/long is sufficient) a ,/u �
N W 90/ 7r/(r/ 1/10/22
Signs of Certified Well Contractor V 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 I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis 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: 105 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(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
II.Borehole diameter: 6 (in.) 24b.For IMeetion Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, 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. I
Form GW-1 North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013