GW1--07562_Well Construction - GW1_20231121

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
John W. Huneycutt 14.WATERZONES i ; -
Y FROM TO DESCRIPTION
Well Contractor Name 378 ft 385 ft. 1 , 1 gpm
2465-A ft. ft 1
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 62 ft 61/8 SDR-21 PVC
Company Name 16.INNER CASING.OR TUBING(geothermal closed-loop) -
2023-00001355 FROM TO • DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. P in.
List all applicable well permits(Le.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) alResidential Water Supply(single) ft. t in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0FROM ft. 3 ft Bent.Chips Gravity
Non Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft. i
❑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 f '
t ft.
❑Experimental Technology ❑Subsidence Control I '
20.DRILLING LOG(attach additional sheets if necessary) -
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.) `
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 30 ft. Brown Dirt _ . { '` :,IT",
_y it .V•;i
L.
7/18/23 30 ff. 55 ft 1 ; Brown Shale ""
4.Date Well(s)Completed: Well ID#
55 ft 440 ft ; Blue Rock N I J V 2 j 2023
5a.Well Location: ft. ft.
Herman K. McDowell ft. ft. •-fi.fs vn
Facility/Owner Name Facility 1Db(if applicable)
E.i'' i't?' y°t
ft. ft. Seams:76',88', 135',150',235',246',
5497 Lakeway Rd., Denton 27239 ft. ft 252-260',310',315',378'=1gpm
Physical Address,City,and Zip 21.REMARKS
Randolph 7701308681
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient) ge4P
� �
N �y ii,17eZt- 8/5/23
Sig ie of Certified Well Contractor Date
6.Is(are)the well(s): GEIPermanent or ❑Temporary
By signing this form,I hereby cert fy 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 1No copy of this record has been provided to the;ivell owner. '
If this is a repair,fill out known well construction information and explain the nature of the
• repair under 1l21 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: 440 (ft) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following: i
i
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (tY.)Ifwater level is above casing use"+" 1617 Mail Service Centier;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 246.For Injection Wells ONLY: In1addition 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:
(ie.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) 1 Method of test: Air
24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfectiontype: Granular Amount 1/2 lb. well construction to the county health department of the county where
• constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013