GW1--07559_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Dwight L. Huneycutt FROATER ZONES
TO DESCRIPTION
Well Contractor Name 219 ft. 225 'ft. I ' 7 gpm
4070-A ft ft. f
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 63 ff. 61/8 ' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00000365 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. TO
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 OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) UResidential Water Supply(single) ft fL 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 Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) `
❑Geothermal(Closed Loop) ❑Tracer FROM TO. DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 • It 13 ft Red Dirt
4.Date Well(s)Completed: 5/25/23 We ID# 13 ft 47 ft Brown Dirt
47 ft 54 ft Brown Rock
5a.Well Location: 54 ft 300 ft Slate
Stanley J. Radford ft ft.
Facility/Owner Name Facility IINi(if applicable) ft ft Seams;118', 129',175',219-225'=7gpm,
Hwy 49,Asheboro 27205 ft. ft
Physical Address,City,and Zip 21.REMARKS. ., - ct.5 ..
Randolph I 7608370427 r. e d ems°L.- ;nJ ii L.�'
County Parcel Identification No.(PIN) •
(, n v ' 1 70
73
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 77 D
tr^
N • W fl/)) ',t6�5i2 ''
Signature o Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certg that:the,wells)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 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: 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: 300 (ft) 24a. For All Wells: Submit this fortis 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: 30 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Air
24e.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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resoulrces Revised August 2013