GW1--02706_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:
14.WATER ZONES
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 62 ft 65 ft 12 gpm (74-79'=3gpm)
4070-A 112 ft 120 ft• I 10 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Derry's Well Drilling, Inc. o it 26 ft 6 1/8 . hi SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023021 W 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. 1'in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
: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:
DMonitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
:Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
[Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rr. ft.
DAquifer Test ❑Stormwater Drainage
ft. ft
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.)
CI Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft Brown Dirt
4.Date Well(s)Completed: 11/30/23 Well ID# 5 ft' 200 ft Blue Granite
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ft. ft. 1
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Sa.Well Location: ft. ft.
Sedberry Family Trust ft ft.
Facility/Owner Name Facility II)#(if applicable)
164 Hall burton Rd, Mt. Gilead 27306 ft 't• Seams:51',56',62'=2g,74'=3g,112'=l0g
Y ft. ft •
Physical Address,City,and Zip 21.REMARKS ff.c'�i'•'' -•r 'r 4s.,Or
Montgomery 7526-00-44-6567 MAY 2024
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: irr?`O ='')r P.Pe ,'!' '' .la U 31
(if well field,one lat/long is sufficient) C<<o; ;.: ,
N W ZGti��L 12/12/23
Signal-m:o Cemfied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,I hereby cert fy lhat the well(s)was(were)constructed in accordance
with 15A 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 ONo 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: 200 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Inflection Wells ONLY:1 In 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:
(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) 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