GW1-2021-01648_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt FROM
WATER ZONES
John W. Hune
y FROi1f TO DESCRIPTION
Well Contractor Name 1 245 rt 255 rt ! 3 gpm
2465-A
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a livable
�� �g3� FROM To DIAIII" TffiCK' nfATFtxrer.
Derry's Well Drilling, Inc. i4mr_ \aA 0 ri• 51 rt• 6 1/8 '° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM I TO I DIAMETER THICKNESS MATERIAL
202000�053
2.Well Construction Permit#: rt• ft• 1n.
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 TMCICNESS MATERLAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal (Heating/Cooling Supply) OResidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft' 3 ri- Bent.Chips Gravity
Non-Water Supply Well:
3 it. 35 ri Bentoniti? Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL E111PLACEMEN-17 METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier D H
❑Aquifer Test ❑Stormwater Drainage
tt. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sotUrock type,grain size etc.
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks 0 ft- 27 ft. Brown Dirt
12/23/20 27 rt 35 ft Brown Rock
4.Date Well(s)Completed: Well ID#
35 r`• 385 rt• Blue Rock
59.Well Location: rt. ft
Jesse Hayden Jarrell u. ft
Facility/Owner Name Facility ID#(if applicable) rt, rt• Seams: 63', 119', 155',245'=3g,312%
1063 Denton Rd., Denton 27239
n. ft. 364'
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:
(if well field one lam/long is sufficient)
N W . 1/15/21
Si rrre of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify thatlthe wells)was(were)constructed in accordance
.vith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well constntction information and explain the nature of the
repair tinder#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 nith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface' 385 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii(dii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Infection 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.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
I '
13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type:
Granular Amount: 1/2 It).
well construction to the county health jdepartinent of the county where
constructed.
Fonn GW-1 North Carolina Department of Environment and Natural Resources—Division of Water ResIom'ees Revised August 2013
I