GW1--05063_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:
John W. Huneycutt 14.WATER ZONES
e- -N,.--.a.. ., �... .,,,, FROM TO DESCRIPTION
Well Contractor Name ('\, L, .t Ei 61 ft- 70 ft- I • 25gpm
2465-A ft. ft.
i A 0 0 0 4 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ilhbr,F,.kn Pry' ',+4iA-g Urx 0 ft. 48 ft- 6 1/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
22-106 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. hi.
List all applicable well permits(i.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
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 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 ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑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- 20 1r. Brown Dirt&Rock
11/14/22 20 ft- 185 ft- Blue Rock
4.Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location: ft. ft.
Jesus Salguero
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:61'=25gpm, 115', 160', 177'
ft. ft.
Duck Creek Ln, Indian Trail 28079(Duck Creek Farms, Lt13) ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 08-216-032
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 CL 4 - (mot./. 11/30/22
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): 127Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of th is 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: 185 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 28 (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 Iniectipn 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
25 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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