GW1--02803_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD
For Internal Use ONLY: �
This form can be used for single or multiple wells
1.Well Contractor Information: I
Dwight L. Huneycutt 14.WATER ZONES ?
g Y FROM TO DESCRIPTIONI
Well Contractor Name 1,,,..A==-•• `_„ ', 'r ,�� I 276 ft 281 it- I 80 gpm
4070-A ft. ft
NC Well Contractor Certification Number MAY 0 6 202'4 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. Ir ft,, .3;r;;P;i-.r.`54,r,.a J o ft 50 ,ft 61/8 SDR-21 PVC
Company Name DWQ'303 16.INNER CASING OR TUBING(geothermal closed-loop)
2022000032 FROM TO DIAMETER'1 THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
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 ill.
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑irrigation . 0 ft 3 n• 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
ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 6 ft. Wet Brown Dirt
4.Date Well(s)Completed: 3/9/23 Well ID# 6 tt 18 ft- i Brown Dirt
18 ft- 25 ft Brown Rock
5a.Well Location: 25 ft- 285 ft j Slate
Devin &Jennifer Driggers
Facility/Owner Name gg Facility lD#(if applicable) ft Seams:70',92-95', 106-109', 117'=3g,
ft.t. f� 134', 149', 162', 191',276-281'=77g
2172 Rocky Cove Ln., Denton 27239
Physical Address,City,and Zip
21.REMARKS
Davidson
County Parcel Identification No.(PIN) •
.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(dwell field,one lat/long is sufficient)
/
N W Z7 f� ,G_. 3/20/23
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby certry that the well(s)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 ONo 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 i
submit one form. SUBMITTAL INSTUCTIONS
I
9.Total well depth below land surface: 285 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdt�erent(example-3@200'and 2@100) 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
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary24a 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) 80 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.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources, Revised August 2013