GW1--01926_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: ,
14.WATER ZONES l -
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name �^^ • 145 ft- 149 ft- I 15 gpm
4070-A , �..,,i r-IW,i1 155 157 10 gpm
NC Well Contractor Certification Number MAR 15.OUTER CASING(for multi-eased wells)OR LINER(if ap Beattie)
�V�A 2 i 2024, FROM TO DIAMETER i THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 65 ft- 61/8 SCR-21 PVC
Company Name 1RSL'i iY'G.i?i t P,r:^c,c"te4,s uns 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-0000144aCi3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft it: l
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 ,n
❑Geothermal(Heating/Cooling Supply) FiResidential Water Supply(single) ft. ft
❑lndustrial/Commercial :Residential Water.Supply(shared) IS.GROUT
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft: 3 , ft• Bent.Chips' Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 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 ❑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) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 17 it. i Red Clay
4.Date Well(s)Completed: 9/25/23 Well ID# 17 ft- 41 ft Brown Clay
41 ft- 55 ft- Brown Rock
5a.Well Location: '
Augusta Construction 55 n 165 ft.
Blue Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft. Seams:109-112', 145-149'=15g,
3096 Gallimore Dairy Rd, Denton 27239 (Lot 2) ft. ft, 155-15T=10g
Physical Address,City,and Zip 21.REMARKS
Randolph 7609598383
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) �(�
N W P�� r 1 10/15/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): I lPernianent or ❑Temporary
By signing this farm,I hereby certify that the well(s).was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: :Wes or ZING 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: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3@200'and 2@l00) 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
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 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