GW1-2023-01739_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Dwight L. Huneycutt FROM ER ZONES
DWI
g y FROM TO DESCRIPTION
Well Contractor Name .t, y,a, ;.`� 312 ft- 315 ft 200 gpm
4070-A It. ft
F t B 1 2023 15.OUTER CASING for multi-cased wells)OR LINER it a livable
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS I MATERIAL
Derry's Well Drilling,_ Inc. 1n=.i,,:. ;"�l=,gip R ur,,J 0 146 ft 6 1/8 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2019-00002392 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. is
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaliPublic ft. ft. is
❑Geothermal(Heating/Cooling Supply) 9111esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 3 fL Bent.Chips Gravity
Non-water Supply well:
❑Monitoring ❑Recovery 3 ft 20 fL Bentonite Pumped
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fL
❑Aquifer Test ❑Stormwater Drainage ft. &
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnen soil/rock type,grain size,eta
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft- 18 ft. Brown Dirt
10/14/22 18 ft 37 & Brown Granite
4.Date Well(s)Completed: Well ID#
37 ft 315 ft- Blue Granite
5a.Well Location: ft. ft.
Elizabeth Young fL ft.
Facility/Owner Name Facility ID#(if applicable)
7693 Adams Farm Rd., Randleman 27317 ft. ft Seams: 116', 150',3or,312-315'=200g
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Randolph 7757642059
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)
11/4/22
N w
Signature of Certified 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 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yea or 9]No 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 ofthe
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
9.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 sense construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 315 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of easing: 10 (fL) 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) 200 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