GW1--05172_Well Construction - GW1_20240830

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
FROM TO DESCRIPTION
Well Contractor Name 235 f` 238 f` lgpm (268-270'=1gpm)
2465-A 405 f` 426 ft- 13gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap. cable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 ft' 80 ° 61/8 in- SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
407615 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(ie.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) FResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 It. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 f` 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 OStormwater Drainage
ft. ft.
0 Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sure,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f` 460 f` Red Rock
t.
4.Date Well(s)Completed: 3/5/24 ft f
Well MN ft.
.
ft.
5a.Well Location: R. ft.
Richard C. Tucker
ft f` Seams: 106', 130',235'=lg,245',268'=lg
Facility/Owner Name Facility ID#(if applicable)
ft f
2221 Crown Rd., Peachland 28133 t 350-392',405-426'=13g
ft. ft.
Physical Address,City,and Zip 21.REMARKS 1 ''.-7
Anson 631900062187
County Parcel Identification No.(PIN) t, 1.7 J t E6?1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Fv '
(if well field,one lat/longissufficient) rt,.&., .:%.. r, ,w.'. '. ;
N W
02.
c/a/ ` ^
Signa of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
with i5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or I]No 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: 460 (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 2Q100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 30 (ft)
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
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