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GW1--05068_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:. A -. _ - Y FROM TO DESCRIPTION Well Contractor Name 158 ft 165 't 12 gpm sA' '"� ' tr. ft 2465-A F"l .r ;��F 185 188 1 gpm 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)'• .- NC Well Contractor Certification Numly r FROM TO DIAMETER THICKNESS MATERIAL Derry's Well Drilling, Inc. AUG 0 A 2023 0 ft 50 ft 61/8 in• SDR-21 PVC Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) ' 3624 ' " ''' Pt,.' 1 UR4tiA FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: j31,$Kb 3 ft ft. in. 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 ft. ft in. ❑Agricultural ❑Municipal/Public . OGeothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in. ❑industrial/Commercial OResidential Water Supply(shared) lS 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): - . FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft. ❑Aquifer Test ❑Stormwater Drainage ft. ft ❑Experimental Technology 0 Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)' : ' ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soiBmeh type,grain size.ere.) ❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 5 ft. Red Dirt 5/4/22 5 ft. 20 ft Brown Dirt 4.Date Well(s)Completed: Well 1D# • 20 ft 200 ft Blue Rock 5a.Well Location: ft. ft. Caleb Kirk ft. ft• Seams:67',90-95', 103', 158'=12gpm, Facility/Owner Name Facility 1D#(if applicable) Richfield Rd, Richfield 28137 ft. ft. 185'=1gpm fL R. Physical Address,City,and Zip 21:REMARKS` Rowan 546 064 County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: • (if well field,one htt/lang is sufficient) ,� )) N W Ina19.94PW. 5/28/22 Siof Cettified Well Contractor Date 6.Is(are)the well(s): ©Permanent or ❑Temporary fly signing this form,I hereby certh'that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We!!Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or FINo 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 ii21 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 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. sums TrAL INSTUCTIONS 9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple welts list all depths if different(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, If water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617 II.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 thin form within 30 days of completion of well 12.Well construction method: ry construction to the following: (i.e.auger,notary,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) 13 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