GW1--02809_Well Construction - GW1_20240506

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt _ FFRONATERZONES DESCRIPTION'
Well Contractor Name 'G-
'.,.. .:1,w, la i, -y 73 ft' 79 ft- I 1 10 gpm
4070-A 94 ft' 101 ft- I I 90 gpm
MAY 0 G 2074
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. Irr;o;A-1. "il -Irr..,;,ir;i4: g UM 0 ft. 46 ft. 6 1/8 SDR-21 PVC
Company Name UAW w t'g` ' 16.INNER CASING OR TUBING(geothermal closed-loop)
2021000027 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
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1s. ROUT
FROMG TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 L 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ORecovery 3 ft- 20 ft- Bentonite' Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
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❑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 sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 8 ft. , ' Brown Dirt
11/9/23 8 ft. 21 ft: ! Brown Rock
4.Date Well(s)Completed: Well ID#
21 ft. 125 ft' ,
Gray Granite
5a.Well Location: ft. ft
William Richard IV ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft- Seams:55',62',73-79'=1 og,94-101'=90g,
1736 Rocky Cove Ln/131 Dalebrook Ct.,Denton 27239(The Springs Lt 63) ft. ft. 106-110'
Physical Address,City,and Zip
21.REMARKS
Davidson
!
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: •
(if well field,one lat/long is sufficient)
N W PGG 5 � GuleG 11/25/23
Signature of ertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or OTemporary 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 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: 125 (ft.) 24a. For All Wells: Submit this foim 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 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Centi r,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: Inladdition to sending the form to the address in
Rotary24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: 1
(Le.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
100 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 dl partment of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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