GW1--05173_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:
Dwight L. Huneycutt F4.WATER ZONESFROM TO DESCRIPTION
Well Contractor Name 350 ft 356 ft 60gpm
4070-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft- 50 R. 61/8 l°• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
369441 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) is
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) OResidential Water Supply(single) 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 Wen: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier f4 ft.
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solProek type,grain use,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 11 R Brown Dirt Rock
5/13/24 11 ft- 365 ft. Slate
4.Date Well(s)Completed: Well IDq R. ft.
5a.Well Location: B. ft•
Paulino Betancourt ft. ,
Seams:61',68',97', 129', 141', 195',
Facility/Owner Name Facility ID#(if applicable) R
Rising Sun Rd., Peachland 28133 ft. ft. 35o'=sog
Physical Address,City,and Zip 21.REMARKS [ ..� ' -.
Anson 631900062187 ; ,
County Parcel Identification No.(PIN) A"('G v 0 2624
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: lr, z,;:7,::,.;'-.; ' .r s
(if well field,one lat/long is sufficient)
N W
Pf --' 6/1/24
Signature of C 'fied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or/SA 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#2/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 wen depth below land surface: 365 (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 1@/00) construction to the following:
10.Static water level below top of casing: 30 owDivision 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) 60 Method of test: Air 24c For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.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