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