GW1--01925_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:
John W. Huneycutt "' 14.WATER ZONES ' • 1 ,
'b...� .-.y _ FROM TO DESCRIPTION
Well Contractor Name •C 1�$t�,,,1, .f ' .t ,"r. 70 ft- 85 ft j 20 gpm
t tf 4 , ft. ft.
2465-A • MAR
NC Well Contractor Certification Number 2 t 20Z4 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO • DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. tnforsx w,,n,P,•. ;_,,I �„ 0 it 42 ft- 61/8 SDR-21 PVC
u ,...
Company Name . 1 ' '' W 16.INNER CASING TUBING(geothermal closed-loop)
2023-00001164 .FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
ft. ft. i t.
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. in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft. ft. to
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM" TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 3 Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 ft- Bentonite; Pumped
Injection Well: - ft. ft.
:Aquifer Recharge_ ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. 1
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 it 25 ft Brown Dirt
8/30/23 25 fr. 140 • ft Blue Rock
4,Date Well(s)Completed: Well DM ft. ft.
5a.Well Location: ft. ft.
Roger Lee Wilson ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams:50',55',65',70-85'=20g,
173 Henley Country Rd., Asheboro 27203 ft ft
i. 85', 120', 134'
Physical Address,City,and Zip 21.REMARKS
Randolph 7771263956 !
County Parcel Identification No.(PIN) i,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N Rt grl"'r �Z�i 9/15/23
Si a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby cert 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 hlNo 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
9.Total well depth below land surface: 140 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(at200'and 2(100) construction to the following:
10.Static water level below top of Lasing: 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 Iniection 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:
(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) 20 Method of test: Air
24c.For Water Supply&InjectioniWells:
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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013