GW1-2023-02717_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 9 . �
Derry L. Huneycutt "rn- -.n. .r° 'a o i!, wl'0 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name A P R 1 12023 70 ft 75 ft 1 gpm
2663-A 287 ft 295 ft 1 gpm
NC Well Contractor Certification Number {f1� ;;;:;;'.0 l
�r C•3,�,:Fi 15.OUTERCASING for multi-cased wells ORLINER(ifa licable
CI.�e ;Jim,{� FROM TO DIAMETER THICKNESS aATERIAL
Derry's Well Drilling, Inc. 0 ft 49 ft 6 1/8 t SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 2020-00000406 FROM ft . TO ft DIAMETER nn THICKNESS MATERIAL
List all applicable well permlis(i.e.County,Slate,Variance,Injection,etc.)
ft. I in.
3.Well Use(check well use): 17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic fr. 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
❑lrri ation 0 ft' 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
$ ft' 20 ft 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 fr. TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer P35ft-
TO DESCRIPTION color,hardness soillrock e, rain sim,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft- 25 ft. Red&Brown Dirt
1/13/23 35 ft. Boulders
4.Date Well(s)Completed: Well ID#
500 ft Granite
5a.Well Location: t. ft.
Judith Miller ft. ft. ,
Seams:57,70—1 gpm,95, 115, 135',
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. 270',287'=1 gpm,325',447',455'
6829 Randall Hurley Rd, Asheboro 27205 fL ft.
Physical Address,City,and Zip 21.REI%IARKS
Randolph 7624741234
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutesAcconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) /
N W ,� 2/11/23
Signature of rtified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 01C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy ofthis 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 tinder#21 remarks section or on the back ofthis 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 o jection or non-water supply wells ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 500 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100� construction to tine following:
10.Static water level below top of casing: 56 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,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:
(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) 2 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013