GW1--02701_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES i-
Y FROM TO DESCRIPTION I
Well Contractor Name 48 ft, 54 ft 1 1/2 gpm
2465-A 390 n 400 fL 1 1 1 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. o f. 36 ft. 6 1/8 4 SDR-21 PVC
Company Name 1
FROM 16.INNER CASING OR TUBING(geothermal closed-loop)
2022017W TO DIAMETER . THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
list all applicable well permits(i.e.Counry.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. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) `18.GROUT
FROTH TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 it, 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,aoilroek type grain she.ete.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 it 10 ft Red Dirt
4.Date Well(s)Completed: 7/21/23 Well 1D# 10 ft 20 ft Boulder
20 ft 500, ft. Granite
5a.Well Location: ft. ft. !
Neil R. Nance
Facility/Owner Name Facility ll)i1(if applicable)
ft. Seams'.48�=1/2g,58',67',71',97', 125',
ft' ft. 132, 187,267,293,297,334,368,
Oak Hills Dr., Troy 27371 (Uwharrie West Lt 6)
ft. 390'=1 g
Physical Address,City,and Zip
Montgomery 7527-00-57-5234 21.REMARKS 1.1 1.•7.,�,la. ,.�I i"....-1.i -
County Parcel Identification No.(PIN) MAY
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: �+`�� 7 L�1�4
22.Certification:(if well field,one lat/lang is sufficient)
e/►tea/�j(B
in- y 8/12/23
N w u°,��.4';,
Sign re of Certified Well Contractor I. Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing this form,1 hereby cert0,that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or ElNo 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 r21 remarks section or on the back ofthis 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-watersiepply wells ONLY with the same construction,you can '
submit one form. SUBMITTAL TNSTUCTIONS '
9.Total well depth below land surface: 500 (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@100) construction to the following: I.
10.Static water level below top of casing: 30 00 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: 1n 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: 1.
(i.e.auger,rotary,cable,direct push,etc.) I'
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i.) 1.5 Alr 24a For Water Supply&Injection Wells:
(gpm)
13a.Yield Method of test: Also submit one copy of this form;within 30 days of completion of
136.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health idepartment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013