GW1--02805_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: ,
Dwight L. Huneycutt "y "„ -��„�� 14.WATERZONES'
G p' � FROM TO DESCRIPTION
Well Contractor Name
.4.:i-•i ii i;' tij 150 ft. 155 ft. 1 1 1 gpm •
4070-A MAY 0 C 2024 f` ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licahle)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. lr43`''"-,` ''P°-' ,` •' 9 um o fL 45 ft• 6 1/8 SDR-21 PVC
riVICJ r 0 16.INNER CASING OR TUBING
Company Name (geothermal closed-loop)
W-23-60 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. !in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. l in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. in "
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 fr. Bentonite Pumped
Injection Well: ft. ft. ;
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 11 ft. !. Red Dirt
4.Date Well(s)Completed: 12/14/23 Well ID# 11 ft. 28 tr• Brown Dirt
28 ft• 285 fe• ! Slate
5a,Well Location: ft. ft.
Rebecca Yates
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. Seams:52', 150'='I g
Jim Rogers Rd., Denton 27239 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Davidson 0902000000002B i'
County Parcel Identification No.(PIN)
- r ,.. . _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one hu/long is sufficient) � � �
N W 12/31/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certq that the well(s)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 BNo - 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
S.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 fonts. 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 ifdii ferent(example-3(200'and 2Q100) construction to the following:
10.Static water level below top of casing: 22 (fL) Division of Water Resources,Information Processing Unit,
Ifseater level is above casing use"+" 1617 Mail Service Center,l Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In 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
(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) 1 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
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