GW1-2022-10017_Well Construction - GW1_20221107

II
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells II{
1.Well Contractor Information:
Dwight L. Huneycutt EG d"` " 14.
RWATERZONES 1' I
� y FROM TO DESCRIPTION
Well Contractor Name 210 f' 215 ft I 12 gpm
4070-A NOV 0 7 2022 ft I f4
NC Well Contractor Certification Number r. ; 15.OUTER CASING for multi-cased wells'OR LINER.if a licable
to oriraUan Pro-. Ft0 Unh FROM TO DIAMETER! THICKNESS nL►TERL►L
Derry's Well Drilling, Inc. DtAlt�ll :DG 0 ft 95 ft 6 118 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2022-00001998 FROM TO DIAMETER', THICKNESS MATERIAL
2.Well Construction Permit#: ft. fr. is
List all applicable well permits(1.e.County,State,Variance,Injection,etc.)
f6 ft. in
3.Well Use(check well use): 17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural E]Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft.
❑IndustriaYCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 3 ft- Bent.Chips, Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft. 20 fL Bentonite" Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To ft. MATERIAL EMPLACEMENT111ETHOD
❑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 saillrock a 'n etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft. 18 ft. Red Clay
8/3/22 18 fL 75 ft Brown Dirt
4.Date Well(s)Completed: Well ID# 75 ft. 82 ft. Brown Rock
5a.Well Location: 82 ft- 225 fL Slate
Eleazer Methodist Church ft. ft.
Facility/Owner Name Facility M#(ifapplicable)
f'• ft: Seams: 108', 113', 130', 148',210'=12gpm
7503 Eleazer Church Rd., Troy 27371 ft. ft.
Physical Address,City,and Zip 21'.REMARKS
Randolph 7614248710
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22•Certification:
(ifwell field,one lat/long is sufficient)
N `,1, r 1 8121122
a Signature of Ce 'fied Well Contractor Date
6.Is(are)the well(s): 101 ermanent or ❑Temporary By signing this form,I hereby certify that the wells)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: ❑Yes or ❑NO copy ofthis record has been provided to the i'vell owner.
If this is a repair,fill out known well construction information and explain the nature of the b
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
may
ay use the back of this page to to
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 j
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 225 (ft.) 24a, For All Wells: Submit this fo h im within 30 days of completion of well
For multiple wells list all depths#different(example-3@2200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- 6 (in.) 24b.For Infection Wells ONLY: Ini 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: Rotary construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,�Raleigh,NC276994636
r
13a.Yield(gpm) 12 Method of test: Air ,W 24c.For Water Supply&Injeclionells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 112 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
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