GW1--02807_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 14.WATER ZONES
9 Y FROM TO DESCRIPTIONI
Well Contractor Name Z• _ ;. - 100 ft- 130 ft- I 10 gpm
4070-AD
• .t .P L..111 r: ft. ft. I
NC Well Contractor Certification Number (Vl/s,hY V G C O�}/,LY 15.OUTER CASING(for multi-cased wills)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 99 ft- 6 1/8 SDR-21 PVC
Company Name ^`'`"'`' " '-'`,"'`ryb''j:3+ t 16.INNER CASING OR TUBING(geothermal closed-loop)
W-23-46 G'IVOL,t� FROM TO DIAMETER 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
fL❑Agricultural ❑Municipal/Public ft m
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
FROM TO MATERIAL; EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft, 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft- Bentonite' Pumped
Injection Well: ft. ft. i
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. I
❑Experimental Technology 0 Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(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. 22 ft Red Dirt
4.Date Well(s)Completed: 11/10/23 Well DV
ft- 35 ft Brown Dirt
35 f4 88 f6 Boulders&Mud
5a.Well Location: 88 ft- 325 ft- Gray Granite
Cliff Maness fL ft.
Facility/Owner Name Facility ID#(if applicable) '
Sierra Trace Rd, Denton 27239 (The Springs, Ph 6) ft. fr. Seams: 100-130'=10g, 140',207',210',
ft. ft. 255',272'
Physical Address,City,and Zip 21.REMARKS
Davidson 09025E0000075
County Parcel Identification No.(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
.72u).e /et--/...... 7VGatratt-
N W 11/25/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certO,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 ElNo 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
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: 325 (ft.) 24a. For All Wells: Submit this forsn within 30 days of completion of well
For multiple wells list all depths ifdprent(example-3@200'and 2@100' construction to the following:
30 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft)
Ifseater 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
Rotary24a above, also submit a copy of thi,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) 10 Method of test: Air 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county healthy 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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