GW1--02703_Well Construction - GW1_20240507

i
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.R WATER
ZONES
FROM TO DESCRIPTION
Well Contractor Name 117 ft. 120 ft, l { 10 gpm
2465-A ft. ft. I '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 51 ft- 61/8 , in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023024W 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
ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) l iResidential Water Supply(single) ft. it. in.,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 R- 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 OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft- 25 ft. Brown Dirt
1/15/24 25 ft• 40 ft- Brown Rock
4.Date Well(s)Completed: Well ID# 40 ft- 165 ft- Blue Rock
Sa.Well Location: ft. ft.
Randy Garner ft. ft.
Seams:59',68',95', 100', 109',
Facility/Owner Name Facility ID#(if applicable)
468 Green Oak Gap, Mt. Gilead 27306 ft.f ft. " 117'=10g, 135', 156'
Physical Address,City,and Zip -: .,•
Montgomery 7525-00-93-8762 21.REMARKS :: �_ ,1, t
County Parcel Identification No.(PIN) M AY (/ 1 LGL4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: s-r i P,-- -d'r
(if well field,one lat/long is sufficient) ltt.v N"p,''i'r C 3 y`':�U.
N W 2/10/24
Signs of Certified Well Contractor Date
6.Is(are)the well(s): 127Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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
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 i
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 ifd different(example-3@200'and 2@100') construction to the following:
Division of Water Res+urces,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
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:
(i.e.auger,rotary,cable,direct push,etc.) 6
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
10 Alr 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this fonri 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 WateriR i ources Revised August 2013