GW1--05079_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD
For Internal Use ONLY: i
This firm can be used for single or multiple wells
1.Well Contractor information:
John W. Huneycutt I4.WATERZONES 1
Y FROM TO DESCRIPTION
Well Contractor Name 385 rt. 392 ft, I 4 gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft, 66 ft, 6 1/8 SDR-21 J PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023010W 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. 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) ❑Residential Water Supply(single) ft. it in.
❑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:
❑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 B gn""' t y ^" `M TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwate bran ag�E i kf 4,P.."' f t. ft.
ft. ft,
['Experimental Technology ❑Subsidence Con r G
)
l4 202'J -20.DRILLING LOG(attach additionatsheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,ha,dness.soilhack type grain sire,etc.)
❑Geothenal(Heating/Cooling Return) ❑Other(ex Ig14nnije Remarkg f %tta ft. 40 ft. Brown Dirt
3/28/23 Dfa`G43 = 40 ft. 55 ft Junky Rock
4.Date Well(s)Completed: Well JIM •
55 ft. 405 ft* Slate
5a.Well Location: ft. ft.
Joseph Honeycutt ft ft
Facility/Owner Name Facility IDk(if applicable)
Hearne Farm Rd., Mt. Gilead 27306 it. ft. Seams:98', 105', 145', 153', 180',
Physical Address,City,and zip ft. ft. 215',310-315',347',385'=4gpm
21.REMARKS
Montgomery 7504-00-44-9129
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer• aholt:
(if well field,one lot/long is sufficient) f /�� t-
�GJ7/ GL!? f1(,'GG(_L. 4/15/23
•
N W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or DTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed In accordance
with 15A 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 EINo 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 021 remarks section or an the bock 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: 405 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 39 (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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 4 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 G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013