GW1--05085_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:
Dwight L. Huneycutt 14.WATER ZONES t
Y f j „• t FROM TO DESCRIPTION
`Well Contractor Name 6j,•,-- 1...,r v v,,) 230 ft• 234 ft• 1 3 gpm
4070-A II ft. ft
NC Well Contractor Certification Number AUG G 0 A 2023 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. htitrst-441).n Prr _p eg Un* 0 ft• 66 ft• 61/8 SDR-21 PVC
Company Name t51"l'li1'�t.s.ti 16.INNER CASING OR TUBING(geothermal closed-loop)
r�r1 010W FROM TO DIAMETER THICKNESS MATERIAL
20
2.Well Construction Permit#: 22 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
•
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft 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 itBentonite 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 OStormwater Drainage it ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft 14 ft Red Dirt
8/2/22 14 ft. 45 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
45 ft. 55 ft• Brown Rock
5a.Well Location: 55 ft• 325 ft* Blue Granite
Miriam Jicha ft. ft.
Facility/Owner Name Facility ID/1(if applicable)
f` aSeams:75',79',85',92', 113-119', 174',
342 Williamson St, Troy 27371
190',
,209',217',230-234-3gpm
Physical Address,City,and Zip 21.REMARKS
Montgomery 7539-00-45-6296
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) q�
N W Z,Gz 9/15/22
Signature of tertified Well Contractor Date
6.Is(are)the well(s): 17Permanent or OTemporary By signing this form I 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#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 the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 325 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2@100) . construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 40 (ft.)
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.es 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) 3 Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.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