GW1-2023-02720_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:
14.WATER ZONES
Dwight L. Huneycutt !ROM r
DESCRIPTION!
Well Contractor Name - 98 ft fL 20gpm
4070-AF... 1n. ft.
APR 1 3 15.OUTER CASING for multi-cased wells OR LiNER if a licable
NC Well Contractor Certification Number
FROM TO DIAMETER THICIINESS MATERIAL
Derry's Well Drilling, Inc. o ft 54 ft 61/8 is I SDR-21 I PVC
Company Name IriiCir7 :J JIi 1:16.INNER CASING ORTUBING eothermalclosed-loo
2022-00002030 DV"�/",r-v'O FROM TO DIAMETER THIC—iss MATERIAL
2.Well Construction Permit#: L G J g• ft I I.
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
% ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ObTigation 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 a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIALEMPLACEMENTMETHOD
[]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,hardness,soilfrock type,grain size,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 ft Red Clay
11/7/22 5 ft 41 ft. Brown Dirt
4.Date Well(s)Completed: Well EN41 ft 325 ft, Blue Granite
5a.Well Location: ft. ft
Larry Green ft tt
Facility/Owuer Name Facility ID#(ifapplicable)
1239 Henley Country Rd, Asheboro 27203 r4 T Seams:61',69',72',90', 135',227',238',
265,272,298'=209pm
Physical Address,City,and Zip 21.REMARKS
Randolph 7772258403
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W � 12/1/23
Signature ofCe?bficd Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that ahe 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 0No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain line nature of the
repair under#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 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 form within 30 days of completion of well
For multiple wells list all depths rjdtjferent(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: 32 (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 24aabove, 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) 20 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013