GW1--02696_Well Construction - GW1_20240507

1
WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATERZONES
g Y FROM TO DESCRIPTION
Well Contractor Name 73 ft 76 ft I f 12 gpm
4070-A •
136 ft 139 fr. I 1 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 50 fr. 61/8 t.. ;a SDR-21 PVC
Company Name16.INNER CASING OR TUBING(geothermal closed-loop)
2022022W FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft 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
❑Agricultural ❑Municipal/Public H. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 20 ft Bentonite Pumped
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
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: 18 ft. Brown Dirt
4.Date Well(s)Completed: 11/28/23 Well ID# 18 ft- 37 ft Brown Rock
37 ft. 165 ft Blue Rock
5a.Well Location: ft. ft.
Joretta Hurley ft. ft.
Facility/Owner Name Facility 106(if applicable) ft, f4 Seams:55',69',73-76'=12g, 136-139'=5g,
4520 Love Joy Rd., Troy 27371 R� <<;
ft f4 rM :_ 'r t
Physical Address City,and Zip e''� ' •r..G.i..�, }
21.RE HARKS
•
Montgomery 7622-00-78-7786
MAY 45 i 2674
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: it'r`.'cii.r'rr:�k,%,••''tn`-r.`'�'`''"y tint:
(if well field,one lat/long is sufficient) ��'f�'— 12/12/23
[ti,,dv CO LH.�
N W DG1erti L
Signature o lied Well Contractor ' Date •
6.Is(are)the well(s): ©Permanent or ❑Temporary i
By signing this form,I hereby certi y that the we (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 EllNo 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 I
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 const ruction,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 ifdifferent(example-3@200'and 2@I00) construction to the following: •
1Q.Static water level below top of casing: 30 (n) Division of Water Resources,Information Processing Unit,
If water 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
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) 17 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