GW1--05071_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD For Internal use ONLY: I '
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt It WATER ZONES. '
Y , :
FROM TO DESCRIPTION
Well Contractor Name 75 ft- 80 ft- 3 gpm
2465-A N.C�,o L:i VE D 190 ft. 200 ft. 7 gpm
NC Well Contractor Certification Number +I U/= 15.OUTER CASING(for multi-cased'wells)'OR LINER(if ap licable)
A U 0 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 71 ft- 61/8 in- SDR-21 PVC
Company Name anforx: ,:,,n Pr , ? unx 16.INNER CASING OR TUBING eothermal closed-loop) - _ -
2022-0000131��`�`ti: a FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 8: ft. ft. 'in.
List all applicable well permits(t.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
0 Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
0 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:
OMonitoring ❑Recovery 3 ft- 20 it- 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 ❑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 it 50 ft- Brown Rock&Dirt
4.Date Well(s)Completed: 11/10/22 Well ID# 50 ft. 60 it Shale
60 ft 265 it Blue Rock
5a.Well Location: ft. ft.
Josh Leonard ft. ft. .
Facility/Owner Name Facility ID//(if applicable)
ft. , it Seams:75'=3gpm,85', 105', 112', 147', 151'
Lou Cranford Rd, Denton 27239
ft. ft. 168', 177', 190'=7gpm,230',250'
Physical Address,City,and Zip 21.REMARKS
Randolph 7605787913
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) J
N W ��) "/, ' 11/30/22
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): I?7Perinanent or ❑Temporary By signing this form,I hereby certfy 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 ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known ire!!construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water 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:
(ie.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
10 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