GW1-2023-02620_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:
14.'*VATER ZONES
Dwight L. Huneycutt FROM TO DESCRnnoN1
135 "' 140 4 gpm
Well Contractor Name
4070-A 196 ft 205 ft 6 gpm
NC Well Contractor Certification Number 15.OUTER CASING for TEI_ ed ells)P LINER(if aplicable)
APR 1 0 2023 6FROM ft. TO DIAMETER TH=S MATERIAL
Derry's Well Drilling, Inc. 08 fL 6 1/8 SDR-21 PVC
Company Name J. 16.INNER CASING OR TUBING(ecothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 40570 ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,InjectioA etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUL
DAgricultural OMunicipal/Public ff. ft. hL
OGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft ft
ra
01ndustrialifCommercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OIrrigation 0 ft 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 n Bentonite Pumped
0monitoring ORecovery
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM & TO ft. MATERIAL EMPLACEMENTMETHOD,
E]Aquifer Test OStormwater Drainage ft ft.
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if nece I ssary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sail/rock type size,etc.)
0 Geothermal(Heating/Cooling Return) 110tker(explain under#21 Remarks) 0 it. 11 ft. Red Clay
Wet Red Clay
4.Date Well(s)Completed: 2114/23 Well M# 11 ft 24 ft.
24 ft- 57 ft. Wet Brown Clay
5a.Well Location: 57 ft 95 ft Brown Grantie
Lynn Kem/Tom Chametzky 95 fL 225 ft- Gray Granite
Facility/Owner Name Facility]D#(if applicable) ft fL Seams: 116',129', 135'=4gpm, 154', 157',
265 Cagle Rd., Seagrove 27341 ft. ft. 188-190', 196'=6gpm,217'
Physical Address,City,and Zip 21.RENIARKS
Moore 20100202
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification:
(if'well field,one Wong is sufficient)
N W 3/1/23
Signature ofMfified Well Contractor Date
6.Is(are)the well(s): ©Permanent 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: ElYes 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 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
&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: 225 (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 2@100) construction to the following:
10.Static water level below top of easing: 38 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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
13a.Yield(gpm) 10 Method of test: Air 24c.For Water Supply&klection Wells:
Also submit one copy of this forni, within 30 days of completion of
13b.Disinfection type Amount 1/2 lb.
Granular well construction to the county health!department of the county where
., :
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013