GW1--07564_Well Construction - GW1_20231121

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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.WATER ZONES 1. .!
Y FROM TO DESCRIPTION
Well Contractor Name 72 ft 90 ft I i 3 gpm
2465-A 168 ft- 175 ft , I 2 gpm
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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- 24 ft 61/8 I: 'in' SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00002350 FROM TO DIAMETER, THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft t in.
List all applicable well permits(i.e.County,Stale,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 ❑Municipal/Public it ft. in '
'
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. In.
❑IndustriallCommercial ❑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)
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❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control ' •
20.DRILLING LOG(attach additional sheets if necessary) .
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(rotor,hardness,soil/rock type,grain size,etc.)
• OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 10 , ft ' >'.i :;; V I-�lBi'own Dirt
9/5/23 ft ft-4.Date Well(s)Completed:. Well ID# 10 ft. 500 tjd I)J S; InnSlate
Sa.Well Location: ft. ft. 14� 1-•
Steven Maness ,t:,- `
Facility/Owner Name Facility lD#(if applicable) R. ft Seahis'72'-90'=3gpm,96-100', 110', 131',
R. ft 168'=2gpm, 190',200',220',288'295',
Woodfern Rd, Seagrove 27341 ft ft. 315',350'
Physical Address,City,and Zip 21.REMARKS " _
Randolph 7687832290
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient) / I
N W ,6 € 2 9/28/23
Si of Certified Well Contractor Date
6.Is(are)the well(s): 127Permanent or ❑Temporary By signing this form,I hereby certtty that the well(s)was(were)constructed in accordance
with 1SANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or InNo 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
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9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: 1
Division of Water Resourrces,Information Processing Unit,
10.Static water level below top of casing: 30 (ft.)
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
Rotary 24a 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this formf 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 Resources Revised August 2013