GW1-2023-01646_Well Construction - GW1_20230213

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: }
This form can be used for single or multiple wells f
1.Well Contractor Information:
14.•WATERZONES l`
Derry L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name �',si.� `� ,1 160 ft 167 ft I 10 gpm
2663-A FEB 1 2023 1186 ft 192 ft 10 gpm
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'wells OR LINER if a Gcable
FROM TO DIAMETER 1 TffiCKNESS MATERIAL
Derry's Well.Drilling, Inc. "'"="`` �' laf�� ' Uih� l"rf o ft- 149 ft 61/8 1. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
373831 FROM TO DIAMETER -THICKNESS MATERIAL
2.Well Construction Permit#: ft % �; in.
List all applicable well permits Ae.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): '17.SCREEN-
Water Supply Well: - FROM TO DIAMETER 1' SLOT SIZE THICKNESS MATERIAL
ft ft. in.j; '
❑Agricultural ❑MunicipaUPublic
❑Geothermal(Hehting/Cooling Supply) OResidential Water Supply(single) ft R in j
❑Industrial/Commercial ❑Residential Water'Supply(shared) 1R GROUT
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring bRecovery 3 ft 20 ft Bentonke Pumped
Injection Well: ft ft I;
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK if a lictible
FROM TO MATERUL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier ft. ft.
❑Aquifer Test" ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necess '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION corog hardness,saiUrock fte,grain she,etc.
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 ft. h Red Dirt
4.Date Well(s)Completed: 9/29/22 Well RM 15 ft- 70 ft. i Brown Dirt
70 ft- 135 ft i ;Brown Hard Junky Rock -
5a.Well Location: 135 ft 200 ft Blue Rock
Rachel Misher ft It.
Facility/Owner Name Facility UM(ifapplicable) % It. Seams: 160-167'=10gpm, 172%
Yadkin Brick Rd., New London 28127 ft. ft
186-192'=10gpm
Physical Address,City,and Zip 21.REMARKS
Stanly 36808 -
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County Parcel IdefitifieationNo.(PIN) I,
5b.Latitude and Longitude in degrees/mioutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W 10/16/22
Signature of ertified Well Contractor ' Date
6.1s(are)the well(s): IOPermanent or .❑Temporary By signing this form,I hemby certo 14(the well(s)was(were)constructed in accordance
i with I SA NCAC 02C.0100 or 15A NCAQ;02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RlNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwuh the same consituctran,you can =
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this Ifornt within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
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10.Static water level below top of casing: 30 (M) Division of Water Resources,Information Processing Unit,
Ifwater level,is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In 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 followimg: !
(ie.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service CelIrt 1 r,Raleigh,NC 27699-1636
24c.For Water Supply&InleclionlWens:
13a.Yield(gpm) 20 Method of test: Air "
Also submit one copy of this forn within 30 days of completion of
13b.Disinfection type: Granular Amoant- 1/2 lb. 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