GW1--01964_Well Construction - GW1_20240325

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
FROM TO DESCRIPTION
Well Contractor Name 95 ft' 70 ft• 15;gpm (137-140'=1gpm)
2465-A 240 it 247 ft- 1 4 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 f6 47 ft• 61/8 i'in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
315607 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ' ft. . M.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in,
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft is
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❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Comercial ❑Residential Water Supply(shared) 18.GROUT
m
FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irrigation -- ..._,„ 0 ft. 3 ft Bent.Chips Gravity •
Non-Water Supply We ' f r .' �' Lit
❑Monitoring c�� 6❑ every 3 ft• 20 f- Bentonitei Pumped
Injection Well: MAR 2 :,, 2024 ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Storage and eym, .)r i1 Pcc C15Satiigyt wirier ., _ft ft.
❑Aquifer Test D140/391St Dra
inage
Drain e
ft. ft. 1.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 ft• , , Red Dirt
4.Date Well(s)Completed: 10/26/23 Well ID# 10 ft. 40 ft1 ' Brown Dirt&Rock
40 f• 250 ft. i, Slate
5a.Well Location: ft. ft.
Timothy Bowers ft: ft' Seamsc60,65-5g,70,90,105,, 115,
Facility/Owner Name Facility KD#(if applicable)
ft. ft. 125',137'=1g, 145', 157', 174', 185',
Kendall Rd., Wadesboro, 28170
ft. fr. 1215',225',230',240'=4g •
Physical Address,City,and Zip 21.REMARKS t
Anson 655100845930 i;
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N `1, W. 7 11/10/23
Sig fCertifiedWellContractor t ' Date
6.Is(are)the well(s): I2lPermanent or ❑Temporary
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or • No copy of this record has been provided to the ivell 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
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9.Total well depth below land surface: 250 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 r@200'and 2@100') construction to the following:
30 Division of Water Resores,Information Processing Unit,
10.Static water level below top of casing: (ft)) uc
Ifwater level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: ID 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: 1
(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
24c.For Water Supply&IniectiontWells:
13a.Yield(gpm) 1 Method of test: Alr 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
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