GW1--02709_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 14.WATER ZONES i ;
Y , FROM TO DESCRIPTION
Well Contractor Name 155 ft. 173 ft• I I 5 gpm
2465-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if all licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 69 ft. 6 1/8 :.in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
#3 FROM TO DIAMETER THICKNESS MATERIAL
41237
2.Well Construction Permit#: (#3) ft. ft. in.
List all applicable wellpennits(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
ft. ft. in.
El.lAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft M.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 f. Bent.Chips , Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 a20 ft. Bentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
DExperimental 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) DOther(explain under#21 Remarks) 0 ft• 60 ft. Brown Dirt
7/1/23 60 ft• 440 ft. ' , Blue Rock
4.Date Well(s)Completed: Well ID#
ft. ft. r
5a.Well Location: ft. ft.
Patrick Robinson
R. ft. Seams:75-80', 120', 130', 135',
Facility/Owner Name Facility ID#(if applicable) ft. ft. 155-173'=5gpm,205-214',220-225',
529 Mt. Carmel Rd, Carthage 28327 ft. ft.
235-240',250',305',407'
Physical Address,City,and Zip 21.REMARKS
Moore 00009793 !,
\.County Parcel Identification No.(PIN) 1, '+--Z-LL'it....t li 1...,a y,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i MAY U 7 2024
(if well field,one laUlong is sufficient) / J
N W �Y" % lit/. GCll� ::P,,.r,q raz/a h23
J' . ,7 raj •./r
Si a of Certified Well Contractor T C"tt'{;f O(Date
6.Is(are)the well(s): OPermanent or OTemporary By signing this form,I hereby cer16,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 0No copy of this record has been provided to die well owner.
Ifthis is a repair,fill out brown 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: 440 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi4erent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ii
11.Borehole diameter: 6 (in.) 24b.For Injection 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
(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) 5 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