GW1-2022-10020_Well Construction - GW1_20221107

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
'r S ���^ � 14.WATER ZONES 1 ;
John W. Huneycutt FROM TO DESCRIPTION
Well Contractor Name NOV 117 135 ft- 140 ft 4 gpm
2465-A In4of,"Pna:ien Pm-c*asgjNJ Unit 190 ft 195 ft 1 gpm 1
NC Well Contractor Certification Number [51Aj�J3 ^ 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER' I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o - ft. 76 ft 61/8 l ih SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop).
2022-00000039 FROM TO DIAMETER' , THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(4 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
ft ft. in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) 23Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water'Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h-ri ation 0 ft 3 ft Bent.Ch.i0s Gravity
Non-Water Supply Well:
3 ft. 20 it Bentonite Pumped
❑Monitoring ❑Recovery
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. j
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnms.soillrock type in sim etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 5 ft 1' Red Dirt
4.bate Well(s)Completed: 5/31/22 Well IDN
5 ft 25 f4 i Brown Dirt
25 ft 45 ft• White Dirt/Sandy
Sa.Well Location; 45 ft- 55 ft Brown Dirt
Patricia Street/David Joyce 55 ft 205 ft Brown Granite
Facility/Owner Name Facility ID#(if applicable)
6781 Meadowbranch Rd., Seagrove 27341 ft f` Seams:17s',85',92', 108', 135'=4gpm, 175',
9 ft. ft 190'=1 gpm
Physical Address,City,and Zip ;21.REMARKS '
Randolph 7695317593
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient) ga&
a) � � ,
N W 6/11/22
Signat66 of Certified Well Contractor Date
6.Is(are)the well(s): 121Permanent or ❑Temporary
By signing this Earn;I hereby certify[hat;the wells)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 E]No copy ofthis record has been provided to the,wetl owner.
ffthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis farm. 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: 205 (ft.) 24a. For All Wells: Submit this forth.within 30 days of completion of well
For multiple wells lisrall depths ifdi ferent(example-3Q200'and 2@100) construction to the following:
I
10.Static water level below top of using: 43 (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use + 1617 Mail Service Centek,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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:
(Le.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) 5 Method of test: Air 24c.For Water Supply&Inlecttop Wells:
Also submit one copy of this forml,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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013