GW1--02806_Well Construction - GW1_20240506

I ,
WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells 1
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES I
9FROM TO DESCRIPTION
Well Contractor Name 292 fL 300 ff I j 3 gpm
4070-A '.: r',., ii 472 ft• 478 ft• I 1 2 gpm
•
NC Well Contractor Certification Number
-�` `"', ,"t' , " 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER' THICKNESS MATERIAL
Derry's Well Drilling, Inc. 'MAY U G 20Z4 0 ft. 45 ft• 6 1/8 tin• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
W-23-41 ''A-,-,ir:::il r 7,-.'llt,rpritkri U`F FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: r old t i O a ft. ft. !in.
List all applicable well permits(i.e,County,State,Variance,Injection,etc.) fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑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: '
❑Monitoring ❑Recovery 3 fL 20 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 10 fL Red Clay&Boulders
4.Date Well(s)Completed: 12/11/23 Well TM
ft. 580 fa Gray Granite
ft. ft. 1
5a.Well Location: ft. ft. '
Lynn Nader ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Sierra Trace Rd., Denton 27239 (The Springs Ph8) ft. ft. Seams:52',73',95', 116', 144', 189',
fL ft. 292'=3g,472'=2g
Physical Address,City,and Zip 21.REMARKS
Davidson 09026A0000127
County Parcel Identification No.(PIN) I,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
i
N W Z7GU� .c_. 12/31/23
Signature of citified Well Contactor Date
6.Is(are)the well(s): OPermanent or OTemporary
13y signing this form,I hereby certify that the rvell(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 EINo copy of this record has been provided to the ivell owner.
If this is a repair,fill out known well construction it formation and explain the nature of the
repair under 1121 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 fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 580 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�erent(example-3@200'and 2(100) construction to the following:
200 Division of Water Resoar 1es,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: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(ie.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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013