GW1--05047_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:
Dwight L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name '`-a' '" t- f4 ft.
? 1,;;-Li,�i a t 69 73 130 gpm (75-79'=l ogpm)
4070-A [� t -" 90 ft 94 ft 10 gpm
NC Well Contractor Certification Number A U G 0 (� 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap usable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. Infor .�),.ri prr.,...,.:,„ 0 ft- 45 6 1/8 SDR-21 PVC
.,. Ur/X
Company Name ' 0:fdt rS'a� 16.INNER CASING OR TUBING(geothermal closed-loop)
22-251 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. • ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. M.
3.Well Use(check well use): 17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public it ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation • 0 u. 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.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 19 ft Brown Dirt
5/5/23 19 ft 125 ft Slate
4.Date Wells)Completed: Well ID# n_ ft. ,
5a.Well Location: ft. ft.
Miriam Davis
ft ft- Seams:69-73'=30gpm,75-79'=10gpm,
Facility/Owner Name Facility ID#(if applicable)
ft. u. 90-94'=10gpm
9601 Black Rd., Midland 28107
ft. ft.
Physical Address,City,and Zip
21.REMARKS
Union 08210001
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)N w D7ti� ,A L 6/1/23
Signature of ertified Well Contractor Date
6.Is(are)the well(s): 121Permanent or OTemporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15.4 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 the nature of the
repair under#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
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: 125 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing 22 (ft) Division of Water Resources,Information Processing Unit,
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
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) 50 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.
1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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