GW1--07561_Well Construction - GW1_20231121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor� Information: , ,
Huneycutt W. t tuneycutt 14.WATER ZONES• i r '
FROM TO DESCRIPTION
Well Contractor Name 188 ft- 202 ft- I ! 2 gpm .
2465-A 370 ft- 375 ft' I j 1 gpm
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 75 ft- 61/8 '"• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00002079 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. im
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 ❑MunicipaUPublic ft ft. in
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft it in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S•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 OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO . DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 50 ft- •Brown Dirt .
11/11/22 50 n. 60 ft Brown Rock P `J,` �I
4.Date Well(s)Completed: • Well DIN 60 ft 445 ft Blue Rock NOV j ZQ23
5a.Well Location: ft. ft •�
James Michael Wagoner ft ft ir,:;;; :.,' n P, -b;, ,
Facility/Owner Name Facility iV/(if applicable) " ;-
ft 1z Seams:130', 151',160', 188-202'=2gpm,"'"`'123
5723 Lou Cranford Rd., Denton 27239
Physical Address City,and Zip 21.REMARKS •
• tt 270',295',313',370'=1 gpm
Randolph 2021-00002079
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) � 1 '
N W t /' 11/25/22
Si lure of Certified Well Contractor Date
i.
6.Is(are)the well(s): 127Permanent or ❑Temporary
13y signing this join,1 hereby certij,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 ElNo copy of this record has been provided to the well oumer.
If this is a repair,fill out brown 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: 445 (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(43100' construction to the following: i '
10.Static water level below top of casing: 30 (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 Infection 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
I
3 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 1 department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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