GW1--05158_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells _ I
1.Well Contractor Information:
Dwight L. Huneycutt 14.
FROM TO DESCRIPTION
Well Contractor Name 148 ft. 154 ft. 10 gpm
4070-A 177 ft. 185 ft. 5 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap citable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft. 125 ft- 6 1/8 SDR-21 PVC
Company Name 16.INNER CASING OR TURING(geothermal closed400p)
2023-00001286 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permitft. 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. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft• ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well: • ` .' .• ,. '
3 ft• 20 ft. Bentonite Pumped �: '
❑Monitoring ❑Recovery 41E.1
yy`� _Injection Well:
ft. ft. NU(] v ) if7�
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicalo� f,' �G�+
FROM TO MATERIAL EMP (.'EMLt'1"i'I1tETROD..
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. Di., " ' ' %,
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
DExperimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 30 ft. Red Dirt
4.Date Well(s)Completed: 4/15/24 Well iD# 30 ft. 68 ft. Brown Dirt
68 ft. 92 ft. Wet Brown Dirt
5a.Well Location: 92 ft. 111 ft Brown Rock
Norman Askew
111 ft. 225 ft- Blue Granite
Facility/Owner Name Facility ID#(if applicable) ft. ft Seams: 132-141', 148'-154'=10g, 171',
Finch Farm Rd., Trinity 27370
ft. ft. 177'=5g, 189'
Physical Address,City,and Zip
21.REMARKS
Randolph 7704097994
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iatllong is sufficient) /
N `,l, t�Gti het,C_.. 7VLui`%q/ - 4/30/24
Signature of ertified Well Contractor V Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 225 (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 (it•) 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 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.) 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