GW1--01928_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- t: '
Y FROM TO DESCRIPTION
Well Contractor Name _ 78 ft 85 ft I 30 gpm
2465-A P__ ,--., :,-, 125 ft 130 ft 10 m 147-155'=60 m
. Is gpm gP )
�—r`, j
NC Well Contractor Certification Numbers 'J I5.OUTER CASING(for multi cased wells)OR LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAR 2 ;;: �024 o ft 74 ft 61/s 'TM SDR-21 PVC
CompanyName C,. �,,; 16.INNER CASING OR TUBING(geothermal closed-loop) - - "
2023OO7W1y"yK� v7 t� :^, !,_Y FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: [r�,`c li` vI5 ft. ft.
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 OMunicipal/Public ft it in.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft tt in.
18.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) -FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 n 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 tt 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 ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control '
30.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#21 Remarks) 0 ft 5 ft. Boulder
4/24/23 5 ft 45 ft Brown Dirt
4.Date Well(s)Completed: Well ID# 45 It 165 ft Blue Rock
5a.Well Location: ft. ft 1
Barbara Seeba
ft. ft. Seams:78-85'=30g,90-95', 105',
Facility/Owner Name Facility I1)/1(if applicable)
ft. ft. 125-130'=l0g, 135', 147-155'=60g
Buchannon Dr., Troy 27371 , ft ft. -
Physical Address,City,and Zip 21.REMARKS -
Montgomery 7632-00-34-3869
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 Wgeiif
ram'/ 5/13/23
Signat of Certified Well Contractor Date
6.Is(are)the walks): ©Permanent or ❑Temporary
By signing this Torn+,I hereby cerlt&that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACj02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RlNo 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 421 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 rfdifferent(example-3@200'and 2@100) construction to the following:
I
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 24b.For injection 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) 100 Method of test: Air 24c.For Water Supply&Injection'Wells:
Also submit one copy of this form within 30 days of completion of
I3b.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