GW1--01929_Well Construction - GW1_20240325

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
John W. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 150 ft- 160 ft 13 gpm (170-180'=2gpm)
2465-A P ('' " -:-.. 190 ft- 195 ft. 1 10 gpm
�` "'''L. i es 4 i'1 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NC Well Contractor Certification Number �O''c FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. MAR 2 �.. 2074 0 ft- 89 ft 61/8 ;in- SDR-21 PVC
CompanyName 16.INNER CASING OR TUBING(geothermal closed-loop) _
~+�-t.:i?n ,r. FROM TO DIAMETER THICKNESS MATERIAL
2023013W '-�V -L'
2.Well Construction Permit#: C31tt(�+s .00 fr. 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 ft. hi.
❑Agricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 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) ❑Tracer FROM _ TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 40 ft Brown Dirt
4.Date Well(s)Completed: 4/27/23 Well DM 40 f• 78 Junky Blue Rock
78 ft 81 ft Sand
sa.Well Location: 81 ft 245 ft. Granite
John Shepard ft. 141',
Facility/Owner Name Facility ID/I(if applicable) Seams: 110, 117, 132, 150-160'=3g,
547 Flint Hill Rd., Star 27366 ft. 170-180'=2g, 190-195'=10g,210',225'
ft.
Physical Address,City,and Zip 21.REMARKS `
Montgomery 7632-00-59-0229
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laf/long is sufficient)
41f.04I'P a). 7VaireZt-
N W5/13/23
SignatnrOf Certified Well Contractor 1. Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this fame I hereby cert fy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC;01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo 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 1121 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: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(jerent(example-3©200'and 2(Qa 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 Infection 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.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 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