GW1-2023-01648_Well Construction - GW1_20230213

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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.WATER ZONES
cu i
g y FROM TO DESCRIPTION
Well Contractor Name ;� :i 267 ft- 270 H' 8 gpm
4070-A FEBft. fL
EB 1 2023 15.OUTERCASING for multi-cased,we8s OR LINER ifa livable
NC Well Contractor Certification Number FROM TO DIAMETER! THIClQVESS MATERIAL.
Derry's Well Drilling, Inc. In;�rr, n ?r _;:.„: : jr., o ft 46 ft
61/8 SDR-21 PVC
Company Name '"` - 16.INNER CASING OR TUBING(geothermal closed-loop)
355845 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. im
List all applicable ivell permits(xe.County,State,Variance,Injection,etc.)
fG ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLAT SIZE THICKNESS MATERIAL
❑ ❑Agricultural Municipal/Public ft ft.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation'' 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 rL 20 rr. Bentonite Pumped
El Monitoring ❑Recovery
Injection Well: % ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To nwTERtAL EMPLACEMENT METHOD
fL ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed-Loop) ❑Tracer FROM TO', DESCRIPTION color,hardness,soillrock IyM grain size,etc. '
❑Geothermal(Heating/Coohng Return) ❑Other(explain under 421 Remarks) 0 ft- 7 ft Red Clay
4.Date Well(s)Completed: 10/19/22 well ID# 7 ft-. 16 ft j' Brown Dirt
16 ft- 285 fL Slate
5a.Well Location:
ft. ft.
Tomrrly&Tina Ross ft. ft.
Facility/Omer Name Facility ID#(if applicable)
36535 Millingport Rd., New London 28127 (Lot 2) ft n seams:55',58',76',89',106-112', 190',
ft rL 229',234',238',267-270'=8gpm
Physical Address,City,and Zip „
21.REMARKS
Stanl� 140303
County Parcel Identification No.(PIN)
5b.Lati de and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient) �C
N w D � I '/ 11/15/22
Signature of ertiSed Well Contractor Date
6.Is(aro the well(S): 12]Permanent or ❑Temporary By signing this form,I hereby certify that the svell(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 t0 an existing well: ❑Yes or 9lNo copy ofthis record has been provided to the Nell owner.
Iflhis is a�vpair,fill out known well construction information and explain the nature ofthe i
repair under#21 remarks section or on the back ofthis 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.Numb I r of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For muI' e injection or non-water supply wells ONLY with the same construction,you can
submit on form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 285 (ft) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multtp a wells Itsl all depths ii rent(example-3@200'and 2@I00) construction to the following:
1
10.Static water level below top ofeasing: 33 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater le el is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter. 6 (in.) 24b.For Iniection Wells ONLY: I Ind addition to sending the form to the address in
24a above, also submit a copy of ith s form within 30 days.of completion of well
12.Well(construction method: Rotary construction to the following: I
(i.e.augetJ rotary,cable,direct push,etc.) i
Division of Water Resources,JUnderground Injection Control Program,
FOR Wt}TER SUPPLY WELLS ONLY: 1636 Mail Service Center,
nter,Raleigh,NC 27699-1636
8 Air
24a For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
� 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 I1 North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013