GW1--02717_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.WATER ZONES
cu
Y FROM TO DESCRIPTION
Well Contractor Name 88 ft 95 ft I I 25 gpm
2465-A 98 ft 105 ft I I 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- 70 ft- 6 1/8 'TM. SDR-21 Pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2023-00002109 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction Permit#: it ft in.
List all applicable well permits(i.e.County,State,Variance,Infection,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 in.
OGeothennal(Heating/Cooling Supply) E lResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring ❑Recovery 3 f- 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
ft ft
•
❑Aquifer Test ❑Stormwater Drainage - ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soivrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 55 ft Brown Dirt
4.Date Well(s)Completed: 2/9/24 Well ID# 55 ft 60 ft Shale
•
60 ft- 140 ft Slate
5a.Well Location: ft. ft. '
Lora Cranford Griffin lb f1• Seams:88'=25g,98-105'=5g, 129',135'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Hwy 49,Asheboro 27205 ft. ft.
Physical Address,City,and Zip 21.REMARKS .. 'I.,...t Y.
` ...r
Randolph 6697477083 i' MAY co 7 3024
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: IlltOrR'•h.`:'Z r''c.4=N w:'.4 Uit'...4
(if well field,one lat/long is sufficient) 22 Cet tifita/tion:� f u`�i trr ADO
W •.. *APL W. � vt-oQ'i- a
Sign a of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certif,,that'the well(s)was(were)constructed in accordance
with 1SA 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 EIINo 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 infection or non-water supply wells ONLY with the same construction,you can j!
submit one form. SUBMITTAL INSTUCTIONS 1
9.Total well depth below land surface: 140 (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:
10.Static water level below top of casing: 30 (a.) 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
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
(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
30 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
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