GW1--01918_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORD Forinternal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES .1 ,
Y FROM TO DESCRIPTION
Well Contractor Name Vt.. Lr + t\a a jtom' 71 ft- 75 ' ft' i 1 gpm (96-99'=1gpm) '
2465-A . „ 260 ft 290 ft. ` . 1 gpm
NC Well Contractor Certification Number MAR 2 'i 2074 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER: THICKNESS MATERIAL
Derry's Well Drilling, Inc. k+t;,;,•('•: .:?;n Pr.a^• ;;;g u;rt 0 ft• 48 ft- 61/8 SDR-21 PVC
Company Name l3W+`',U`y 16.INNER CASING OR TUBING(geothermal closed-loop)
361944 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit It: 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
❑Agricultural ❑Municipal/Public ft fr in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
FROM ,TO MATERIAL : EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring DRecovery 3 ft. 20 ft. Bentonite Pumped
Injection Well: ft. ft. ,
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
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/rock type,Rhin size,etc.)
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 , ft- 3 rt. Red Dirt
4.Date Well(s)Completed: 5/3/23 Well Mil3 ft. 40 ft. Brown Dirt&Rock
40 ft. 300 ft. i, Slate
Sa.Well Location: •
ft. ft
Kelly Taylor ft.. ft- Seams:71-75=1 g,77',96-99._1 g, 105',=
Facility/Owner Name Facility ID#(if applicable)
630.Bridlewood Dr., Gold Hill 28071 ft. rt. 128',136', 145', 155', 175',208',220',
ft. ft. 230',240',255',260-290'=1g
Physical Address,City,and Zip 21.REMARKS
Rowan 385A018
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one latilong is sufficient)
N W 6f/. 6/15/23
Sit o.`le of Certified Well Contractor I Date
6.Is(are)the well(s): (Permanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
- with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes 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 j
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
S.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 oneform. SUBMITTAL INSTUCTIONS-
9.Total well depth below land surface: 300 (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:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
If water 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 - . .
13a.Yield(gpm) 3 Method of test Air 24c.For Water Supply&Injection Wells s .
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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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