GW1--01930_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:
L. Huneycutt 14.WATER ZONES - i
Dwight
Y FROM TO , DESCRIPTION
Well Contractor Name T•. 81 ft 86 ft 13'gpm (94-97'=2gpm)
4070-A '. Le 9,n-.t;,' L,) 175 fI. 180 ft. ; , 5 gpm
MAR 2 L O L4 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 48 ft 61/8 'a SDR-21 PVC
Company Name 1111i::Fra.ten i">r:..•,A.i'r.-: 0'631 16.INNER CASING OR TUBING(geothermal closed-loop)
2023001Wi4'C�30 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. 'in' r
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 in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft "'
❑Industrial/Commercial ❑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 ❑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) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 27 ft. Brown Dirt
5/5/23 27 ft 33 ftBrown Granite
4.Date Well(s)Completed: Well ID#
33 ft 48 ft Blue Granite
5a.Well Location: ft. ft.
Alex Allsbrook ft. ft• Seams:55',68',77',81'=3g,94-97'=2g,
Facility/Owner Name Facility ID#(if applicable)
648 Hallyburton Rd, Mt. Gilead 27306 ft ft' 109', 116', 127',134', 159', 175'=5g
y ft. ft.
Physical Address,City,and Zip 21.REMARKS 1 _
Montgomery 7526-00-20-7760
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 PGU -� 5/30/23
Signature of Certified Well Contractor Date
6.Is(are)the well(s): l7lPermanent or ❑Temporary By signing this form,I hereby cent*that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 INSTUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdyferent(example-3@200'and 2(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 Iniection 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:
(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) 10 Method of test: Air 24c.For Water Supply&Injeetionl 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