GW1-2023-02617_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Dwight L. Huneycutt 14.WATER ZONES
i FROM TO I DESCRIPTION
Well Contractor Name 565 f" 575 fL 2 gpm
APR
4070-A 1 0 2023 & ft. I
NC Well Contractor Certification Number 15.OUTER CASING for T!±=,,Pd wells 0 R "lopycablel
T
FROM TO g MATERIAL
Derry's Well Drilling, Inc. 0 fl- 60 ft 161/8 to I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING Neothermal closed-loop)
2.Well Construction Permit 41: 41793 FROM ft. TO ft. DIAMETER THICKNESS MATERIAL
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 SLOTSIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in..
DGeothermal(Heating/Cooling Supply) FIResidentiall Water Supply(single) & ft. in.
01ndustrial/Commercial oResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
Oldonitoring ORecovery 3 rL 20 .. rt- Bentonite Pumped
Injection Well: ft. ft
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACKfifapplicable)'
OAquifer Storage and Recovery OSalinity Barrier FROM ft. I TO I MATERIAL I EMPLACEMENT METHOD
IL
DAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer TO DESCRIPTION(color,hardnem,sail/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft, 12 ft. Brown Clay
4.Date Well(s)Completed: 2/15/23 Well W# 12 ft- 23 ft. Wet Brown Clay
1
FROM
2
OM I ft I
23 50 ft. Brown Dirt
5a.Well Location: 0
50 F.605 Blue Granite
Thurston & Kathleen Brown ft. M
Facility/Owner Name Facility ID#(if applicable) ft
ft. ft Seams:69',76,84% 134', 150', 159',
3045 Spies Rd, Robbins 27325 ft
ft. ft. 168', 175',565'=2gpm
Physical Address,City,and Zip . .....
21.REMARKS
Moore 00013710
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattlong is sufficient)
N W 3/14/23
Signature of Certified Well Contractor V Date
6.Is(are)the well(s): 101'ermanent or OTemporary By signing this form I hereby certify that the well(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 to an existing well: DYes or E]No copy ofthis 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:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
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 forma SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 _(fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths y'different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 45 (ft) Division of Water Resources,Information Processing Unit,
Ifivater 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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
1 1
13a.Yield(gpm) 2 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