GW1--01922_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES 1
9 FROM TO DESCRIPTION '
Well Contractor Name r L: if t, 96 ft- 98 fr. 11 gpm (129-133'=7gpm)
4070-A MAR 2074 175 ft- 180 ft- I ! 52 gpm
NC Well Contractor Certification Number M A ` 2 c 15.OUTER CASING(for multi-cased wells)OR LINER(if ap,licable)
FROM 'TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. infi.,rr;,r cp,71; m033..;. ;r.;-um o ft- 72 ft- 61/8 1D• ' SDR-21 PVC
Company Name Dt:`JOJ-G 16.INNER CASING OR TUBING(geothermal closed-loop) -
2023-00001419 FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: 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
ft. in.❑Agricultural ❑Municipal/Public f4 _ ,
OGeothermal(Heating/Cooling Supply) ]Residential Water Supply(single) ft. ft. 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:
OMonitoring ❑Recovery 3 It. 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 ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) ,
0 Geothermal(Closed Loop) OTracer . , FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 15 ft. it ' Red Clay
9/26/23 15 ft- 31 ft- , Wet Brown Clay
4.Date Well(s)Completed: Well ID#
31 ft.- 41 ft- !'Boulders/Junky Rock
5a.Well Location:
•
41 ft- 63 ft- • Brown Granite
Augusta Construction 63 ft- 185 ft- Blue Granite
Facility/Owner Name Facility ID//(if applicable)
ft. ft. Seams:88',96'=1 g, 129'=7g,
Gallimore Dairy Rd, Denton 27239 (Lot 3) . '
rt. ft. ;, 175'=52g
Physical Address,City,and Zip 21.REMARKS
Randolph 7609599144 , ,
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i
(if well field,one lat/long is sufficient)
N W DGw, t L 10/15/23
• Signature of tertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary '
By signing this form,I hereby certt&that;he 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 17.1No 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 021 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 eonstruciian,you can
submit one form. SUBMITTAL INSTUCTIONS
i!
it thi
9.Total well depth below land surface: 185 ' (ft.) 24a. For All Wells: Subms form 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 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i.
13a.Yield(gpm) 60 Method of test: Air 24c.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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013