GW1--05046_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells ,
1.Well Contractor Information:
r; r- a 14.WATER ZONES "
John W. Huneycutt 4 t.. rig'v.,-
.,. � FROM TO DESCRIPTION'
` �-rr.a. Ld,I
Well Contractor Name �-! 150 ft 177 ft 1 3 gpm
2465-A A U G 0 4 2023 235 ft 245 ft. I 32 gpm'
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
IflforuY+ak1 P f - [ e4 FROM TO DIAMETER THICKNESS MATERIAL
Ufa
Derry's Well Drilling, Inc. 1:34.1v iRoo, 0 ft 45 ft 6 1/8 fit SDR-21 PVC.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) -
22-409 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) it. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in. i
❑Agricultural ❑Municipal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.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
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
DExperimental Technology ❑SUbsidence Control -20.DRILLING LOG(attach additional sheets if necessary)
0 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 25 ft Brown Dirt
6/6/23 25 ft _265 ft Slate
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft ft.
Alexander Gaebe
ft ft Seams:77',97', 116', 136', 150-177'=3gpm,
Facility/Owner Name Facility ID#(if applicable)
1408 Summerlin Dairy Rd, Wingate 28174 ft . ft 190',205',235-245'=32gpm
Physical Address,City,and Zip 21.REMARKS
Union 09-090-021
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 2841
�� 11N W g ' a . 7/1/23
Si of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certfy 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 well 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 th is 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
Division of Water Resources,Information Processing Unit,
10,Static water level below top of casing: 28 (ft.)
Ifwater 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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 35 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.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013