GW1--05160_Well Construction - GW1_20240830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.John W. Huneycutt FR MATER ZONES TO DESCRIPTION
Well Contractor Name 132 ft. 135 ft. 10gpm
2465-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap •able)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 47 ft• 6 1/8 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2024004W 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
ft. ft. in. •
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ifJResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 ft- 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 ❑Salinity Barrier ft . ft.
❑Aquifer Test ❑Stormwater Drainage B. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sod/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 25 ft- Brown Dirt
4.Date Well(s)Completed: 4/26/24 Well ID# 25 f't• 240 ft. Slate
ft. ft.
5a.Well Location: ft ft.
Blossom Street Development Grp rt.
Seams:57',75',92', 100', 115', 132'=10g
Facility/Owner Name Facility 1Dit(if applicable) ft.
157', 188',215',225',235'
Low Water Bridge Rd., Troy 27371 ft.
Physical Address,City,and Zip 21.REMARKS . _ _
Montgomery 7603-00-52-9833
County Parcel Identification Na(PIN) t1 1 ,.. rj
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: A1.16 V Eb74
(dwell field,one lat/long is sufficient) `ti
N W 4: W•J
�LU'LQ r- ,,._..?/95/ 4:,,
Si re of Certified Well Contractor G - 'D'3fe
6.Is(are)the well(s): h7Permanent or ❑Temporary By signing this form,I hereby ceritfr that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1 5A 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 421 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 necrccary.
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: 240 (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 Injection 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
ILWell 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
10 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013