GW1--02708_Well Construction - GW1_20240507

WELL CONSTRUCTION RECORD Forhtieinal Use ONLY: 1 '
This form can be used for single or multiple wells
1.Well Contractor Information: '
Huneycutt 14.WATER ZONES '
John W. Hume
Y FROM TO DESCRIPTION
Well Contractor Name 335 ft- 345 ft. I ! 20 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- 90 ft- 61/8 i'in SDR-21 PVC
Company Name l6.INNER CASING OR TUBING(geothermal closed-loop)
41236 (#2) FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. . in.
List ail 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.IZJAgricultural ❑Municipal/Public ft m
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it ft. in
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Mitigation 0 ft, 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft- 20 a 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 it. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 40 ft- Brown Dirt
6/28/23 40 it 80 11- Blue Dirt
4.Date Well(s)Completed: Well ID#
80 ft- 600 ft- Blue Rock
5a.Well Location: ft. ft.
Patrick Robinson
Facility/Owner Name Facility ID#(ifapplicable) ft. ft Seams:125-150', 160', 168', 172', 194-200'
ft. ft. 216'-225',230',245',255-260',313',
529 Mt. Carmel Rd, Carthage28327
ft. ft. 335-345'=20g,430',455',470',537',581'
Physical Address,City,and Zip 21.REMARKS
Moore 00009793 •t{ -; n—I'a. s,
County Parcel Identification No.(PIN) Itt -tr, S-,.e 4„y i V f";1 j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: MAY !I 7
(if well field,one lat/long is sufficient) ,, )l 2024
N W Z• W. Y r I, pn ,. 7 1133
Si of Certified Well Contractor ryPc r:4:z;;0,3 Date
6.Is(are)the well(s): IZiPermanent or ❑Temporary By signing this form,I hereby certioi that;the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACj02C.0200 Well Construction Standards and that a
7.Is 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#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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 600 (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@/00') construction to the following: i,
10.Static water level below top of casing: 30 - , , (fi.) 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 infection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: i '
(i.e.auger,rotary,cable,direct push,etc.) i,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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 healthy department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i