GW1--02698_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells !
1.Well Contractor Information:
L. Huneycutt 14.WATER ZONES t
Dwight
Y FROM TO DESCRIPTION
Well Contractor Name 76 ft. 80 ft. I I 2 gpm
4070-A ft ft. i I
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 51 ft 6 1/8 i"• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023022W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft j in.
List all applicable well permits(i.e.Counry,State,Variance,Injection,etc.)
ft. ft I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: , FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. ft. in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
0 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:
OMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rt. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. '
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sac,etc)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 7 ft. Red Dirt
9/8/23 7 ft 25 ft. Brown Dirt
4.Date Well(s)Completed: Well ID#
25 ft 33 ft. i Brown Rock
5a.Well Location: 33 ft 325 ft I Slate
Michael Freeman
ft. ft. Seams:59',72',76'=2g
Facility/Owner Name Facility IDN(if applicable)
ft. ft.
721 Dennis Rd., Troy 27371 (Hidden Lake, Ph 5) n ft ,.,.. cr., ,.,, n, , .�._
Physical Address,City,and Zip 21.REMARKS e; ir.k,..'',,...•a.....f. V l.�it„�'
•
Montgomery 6589-15-64-5558 MAY
A n. r �(;
County Parcel Identification No.(PIN) IVIi'1Y v i n rs•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: lT Gi pA,4'r,i� FI",1,ri-,r.'<;(ii4
(if well field,one latHong is sufficient) ,[—/ , 7V E.v'7�'t,=;'`_t, 's 9/24/23
N W
Signature o ertified Well Contractor i' Date
1
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo 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 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: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 2@100) construction to the following: ,,
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)
Ifwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:11ti addition to sending the form to the address in
Rotary 24a above, also submit a copy of phis 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) 2 Method of test: Air
24e.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