GW1--01923_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
,; ate "',�"'"' ;..-, FROM TO DESCRIPTION
Well Contractor Name 3. kr..=Ls I.:%' L 76 ft• 81 ft. 3 gpm (105-107'=2gpm)
4070-A MAR 2 & 2024 252 ft. 255 ft. I ' 70 gpm
NC Well-Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap.licable)
FROM TO DIAMETER I . THICKNESS MATERIAL
• r tnfi''''''".---.4 n' .-- N.',,: a L70' 0 ft. 54 ft• 61/8 '°• SDR-21 PVC
Derry's Well Drilling, Inc. 'A'C ,n,Z •
Company Name �.1 ' `�� 16.INNER CASING'OR TUBING(geothermal closed-loop)
P Y
2022-00001569 FROM TO DIAMETER- THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well permits(i.e.Counry,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.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt ft is '
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft, Bent.Chips Gravity
1 Non-Water Supply Well:
3 ft- 20 fc Bentonite Pumped
❑Monitoring ❑Recovery
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 ❑Storrnwater Drainage r
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO ' DESCRIPTION(color,hardness,solltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 42 ft• Brown;Dirt,Loose Rock&Boulders
7/17/23 42 rr• 285 rr• Blue Granite
4.Date Well(s)Completed: Well ID# ft ft.
1'
Sa.Well Location: ft. ft.
Strieby Wood LLC ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. fr. Seams:69',76-81'=3g,105'=2g,
5630 Strieby Church Rd, Asheboro, 27205 ft. ft.
252-255'=70g
Physical Address,City,and Zip
21.REMARKS
Randolph 7626102258
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one lat/long is sufficient) 22.Certification: r,{/
N W Z7 i L J ` 'ritt-- 8/5/23
Signature o ertified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary +'
By signing this form,I hereby certi that the wells)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 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
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 one form. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: 285 (t't.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@I00') construction to the following:
I
10.Static water level below top of casing: 30 (B-) 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: l'In'addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,1Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service f Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 75 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