GW1--05084_Well Construction - GW1_20230804

1
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 S ;
FROM TO DESCRIPTION
Well Contractor Name p 'r"".%jr" S o.., 247 ft- 255 ft I 2 gpm
2465-A ' 1' 4'' -r 1/ Uft ft.
NC Well Contractor Certification Number Q U G :1 023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
V FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 77 ft 61/8 in- SDR-21 PVC
Company Name t ", �]Una 16.INNER CASING OR TUBING(geothermal closed-loop)
2022013W D1+W' '�a 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
ft. ft. in.
❑Agricultural OMunicipal/Public
' ['Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) IS.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 ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) . OTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 10 ft - Red Dirt
4.Date Well(s)Completed: 1/16/23 Well ID# 10 ft- 65 ft Brown Dirt&Rock
65 ft 425 ft Blue Rock
5a.Well Location: ft, ii.
Douglas Auman ft ft.
Facility/Owner Name Facility ID#(if applicable)
HolidayDr., Troy27371 ft ft Seams: 125', 130', 145', 168', 190',205',
ft ft 227',247-255'=2gpm,310',327',370'
Physical Address,City,and Zip 21.REMARKS
Montgomery 6588-18-31-4727
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) geid•P
'',, //
N W . 2/1/23
Si le of Certified Well Contractor Date
6.Is(are)the well(s): ElPermanent 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 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#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 tire same construction,you can
submit one fonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 425 (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@100) construction to the following:
10.Static water level below top of casing: 45 (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 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) 2 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.
IF
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013