GW1-2023-02618_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: I I
John W. Huneycutt 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name 368 ft
1375 1 gpm
2465-A APR j0 023 ft1 it I : I
NC Well Contractor Certification Number ;n' IS.OUTER CASING for multi-cased wells 0 R I apic"I"C'
mAML.' T%UM-L FROM TO W MATERIAL
Derry's Well Drilling, Inc.
ft.
0 1102 ft- 161/8 iD1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(I!eothermal closed-loov)
2.Well Construe.tion Permit#: 40468 FROM ft. TO ft. I DIAMETER in. THICKNESS I MATERIAL
List all applicable well permits(ie.County,State,Variance,Injection,etc.) it f, in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
DAgricultural CMunicipallPublic; ft ft in.
DGeothermal(Heating/Cooling Supply) R311esidential Water Supply(single) ft. ft in.
Ohidustr-a Commercial OResidential Water Supply(shared) 18.GROUT
FROM I TO 51ATERUL EMPLACEMENT METHOD&AMOUNT
OIrrigation 0 it' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
OMonitoring DRecovery 3 ft- 20 ft- Bentonite Pumped
Injection Well: ft. ft.
OAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if2pp livable
)
OAquifer Storage and Recovery ElSalinity Barrier FROM ft. TO ft. MATERIAL I EMPLACEMENTMETHOD
ClAquifer Test OStormwater Drainage ft. ft
DExperimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) ElTracer FROM TO DESCRIPTION(color,hardness,soillrock type sue,etc.)
ClGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 It. 15 ft. Red Dirt
4.Date Well(s)Completed: 10/5/22 Well HM 15 it. 85 ft. Brown Dirt
85 ft- 400 ft- Blue Rock
Sa.Well Location: ft ft
Yolanda Scotton ft . . Seams: 110', 115', 155', 160', 170',205',
Facility/Owner Name Facility M#(ifapplicable) ft. ft. 235',250',255',295',310',325',345',
460 Scotton Rd., Robbins 27325 ft. ft 350',368'=1gpm —
Physical Address,City,and Zip 21.REMARKS
Moore 00012679
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwelI field,one latAong is sufficient)
N W 96�& 10/25/22
Signa of Certified Well Contractor Date
6.Is(are)the well(s): 1211'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 ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or E]No copy ofthis record has been provided to 1)ie well owner.
If this is a repair,fill out known well construction information and explain 1he nature of the
repair under 921 remarks section or on the back ofthisfornz. 23.Site diagram or additional well details:
I You may use the back of this page to provide additional well site details or well
S.Number of'wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY ivith the same construction,you can
submit one form. SUBMITTAL INSTUCFIONS
9.Total well depth below land surface- 400 —(ft.) 24a. For All-Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths itdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 56 (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
12.Well construction method: Rotary 24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 '
13a.Yield(gpm) 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. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013