GW1-2022-10022_Well Construction - GW1_20221107

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WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or mnitipl6 wells
1.Well Contractor Information:
John W. Huneycutt 14.WATER ZONES s i
y FROM TO DESCRIPTIONI
Well Contractor Name «� "�' 233 ft• 240 ft- 1 1 8gpm
2465-A E"�a,,rt b d� ft ft.
NC Well Contractor Certification Number N O V if t 20 22 15.OUTER CASING for multi-cased wells OR LINER if n liea6le
FROM TO DIAMETERC ! THICIdVESS MATERIAL
Derry's Well Drilling, Inc. 0 ft. 84 ft- 61/8 SDR-21 I PVC
Company Name Invrs{ t�1 ra: d 16.INNERCASING ORTUBING(geothermal dosed-loop)
115299 '�`�Q/B0 FROM TO DIAMETERi. THIC[OVFSS MATERIAL
2.Well Construction Permit#: ft. ft. 1n
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- SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) ft. R rn I
❑ FR
Industiial/Commercial ❑Residential Water Supply(shared) GROUT
FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 3 ft Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 ft, Bentonite Pumped
El Monitoring' ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft.
EMPLACEMENT nfETBOD
ft. i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control f L R
I ,
20.DRILLING LOG attach additional sheets,if necess =
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardnrss,soil/rack type,gFWn she,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 & 5* ft Red Dirt
5/25/22 5 ft 40 ft ;i Brown Dirt
4.Date Well(s)Completed: Well ID# ,
40 ft 75 ft ;' Shale Rock
Sa.Well Location: 75 ft 260 ft Blue Rock
Lary Bridge & ft
Facility/Owner Name Facility ID#(if applicable) j
ft fr. Seams:;�120', 135', 162', 175',233'=8gpm,
Moonshine Or., New London 28127 ft ft 245'
Physical Address,City,and Zip
21.REMARKS'.
Stanly 16913
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) ��'� 1
N w /G�i 6/15/22
S' ature of Certified Well Contracto i`, Date
6.Is(are)the well(s): @Permanent 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 0No copy ofthis record has been provided to the well orfvner.
If this is a repair,fill out known well construction information and explain lire nature of the ,.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to!provide additional well site details or well
S.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 INSTUCITONS S
9.Total well depth below land surface: 260 (ft) 24a. For All Wells: Submit this fount'within 30 days of completion of well
For multiple wells list all depths ifdWerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:
33 {ft) Division of Water,Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: Jaddition to sending the form to the address in
Rotary 24a above, also submit a copy of this'(rm within 30 days of completion of well
12.'Well construction method: 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 276994636
13a.Yield(gpm) 8 Method of test: Air 24c.For Water Supply&Infection 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 Res( Revised August 2013