GW1--02700_Well Construction - GW1_20240507

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
John W. Huneycutt 1WATER ZONES i 'I
Y FROM TO DESCRIPTION
Well Contractor Name 58 ft, 70 ft. I I 2 gpm
2465-A 270 ft• 273 D• I I 4 gpm
NC Well Contractor Certification Nnmlvr 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 45 ft, 61/8 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023005W 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. ft. in.
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO , DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural •❑Municipal/Public ft ft m
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. »'
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lnigation 0 ft. 3 fc Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft• Bentonite Pumped
injection Well: .ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
❑A lllfer Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL EMPLACEMENT METHOD
q g Salinity ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft, ,
DExperimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(canoe.hanloess.soilirock type.graIn size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 15 ft. Brown Dirt
6/12/23 15 ft, 40 ft• Boulders
4.Date Well(s)Completed: Well J. 40 it• 300 it I Granite
5a.Well Location: ft. • ft.
Randy Seegars ft. . fL Seams:58-70'=2gpm,76',85', 110', 125',
Facility/Owner Name Facility ID/(if applicable)
c 136', 150', 160', 169', 197',210',227',
Hwy 24/27 W, Mt. Gilead 27306
Physical Address,City,and Zip 21.REMARKS 5 R ^•- 249',270'=4g,275
Montgomery 6586-00-98-7101 • ° c " r v 4-0
County Parcel identification No.(PIN) MAY u i 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/lang is sufficient) 'IZi1� 1 5 1'l. ° :
-u•5:74P..a URA?t, 7/1/23
N W `
Siv..of of Certified WellCotulactor • Date
6.Is(are)the well(s): GaPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
with 1SA NCAC 02C.0100 or 1 SA 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 ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the I.
repair under'421 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--rater supply wells ONLY with the same construction,you can •
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 300 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2(100) construction to the following: 1
10.Static water level below top of casing: 30 (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 Infection Wells ONLY: lri addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
I;
Air 24c.For Water Supply&Injection Wells:
Method of test:13a.Yield(gpm) 6- -_ 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
1