GW1-2023-01652_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt 14.WATER ZONES 4 1
FROM TO I DESt9HPTION I
Well Contractor Name 133 fr• 140 ft 25 gpm
it
ft.
2023 15.OUTER CASING for multi cased webs OR LINER if a livable
NC Well Contractor Certification Number FROM TO DIAMETER b THICIflVESS MATERIAL
Derry's Well Drilling, Inc. �..r�;� o ft 48 '� 61/8 SDR-21 I PVC
Company Name -1; 5!yfj 16.INNER CASING OR TUBING(geothermal dosed-loop)
118164 FROM To DIAMETER;' THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft n
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
% ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLUIETER :SLOT SIZE THICKNESS HATERIAL
ft ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft in ;
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
FROM TO bIATERUL EMPLACEMENT METHOD&AMOUNT
0hrigation 0 ft 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 a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft To MATERIAU: EMPLACEMENTMETHOD
,
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
' 20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION,(color,hardness,soillrock size,etc.)
❑Geothermal eating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft 5 ft Red Dirt
4.Date Well(s)Completed: 5/26/22 Well 1D4 5 ft 15 ft Brown Dirt
15 ft 165 ft Blue Rock
So.Well Location: ft. ft
Leif Romberg ft ft
Facility/Owner Name Facility ID#(if applicable)
Rid ebrook Ln, Locust 28097 ft & Seams:46', 133'=25gpm, 154'
9 ft, ft.
Physical Address,City,and Zip 21.REM1fARKS
Stanly 35686
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrm/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) /
N W 6/15/22
Signature ofCei§6ed Well Contractor, Date
6.Is(are)the well(s): OPermanent or ❑Temporary
B1'signing this form,1 hereby certify thar'the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the ivell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the hack ofthisform. 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 INSTUCTIONS
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9.Total well depth below land surface: 165 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3@200'and 2®100) construction to the following:
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10.Static water level below top of casing: 22 (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: i) (in.) 24b.For infection Wells ONLY: ll addition to sending the form to the address in
Rotary. 24a above, also submit a copy of s(form 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 Ceute`r,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test: Air 24a For Water Supply At 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.
Farm GW-I North Carolina Department of Enduonment and Natural Resources—Division of Water Resources Revised August 2013
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