GW1-2023-01653_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:
John W. Huneycutt T�^ 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name i; j u _. 1 195 ft 200 ft• I I 1 gpm
2465-A FED 1 W�� ft ft. I
NC Well Contractor Certification Number 2023 15.OUTER CASING for multi cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL.
Derry's Well Drilling, Inc. 0 fr 45 ft' 16 1/8 ',' SDR-21 I PVC
Company Name
"�✓'u vji 16.INNER CASING OR TUBING eothermal closed-loop)
310017 FROM TO DIAMETER THICKNESS HLATERIAL
2.Well Construction Permit#: tt fr. ;in.
List all applicable well permits C1.e.County;State,Variance,Injection,eta) _ ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
ft St. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cpoling Supply) lDResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft 3 ft Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft Bentonite Pumped
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I 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 necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrork type,grain Am eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 16 ft Red Dirt
4.Date Well(s)Completed: 3/24/22 Well ID# 16 ft 32 ft r Brown Rock
32 ft 445 ft- Blue Rock
5a.Well Location: tt
Michael Overman n
Facility/Owner Name Facility ID#(if applicable)
ft ft il 42033 Canal Rd, New London (Lot 17) ft. Seams: 137',195'=1gpm
Physical Address,City,and Zip
21.REMARKS'. ! •
Stanly 8684 !'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Ce 'firalion:
(ifwell field,one tat/long is sufficient) ,, J
4/19/22
N W
Sign re of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 itereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair t0 an existing well; ❑Yes or 91No copy ofthis record has been provided to the well'ouner.
If this is a repair,fill out known ivell construction information and explain the 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 ofwelis constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can SUBMITTAL INSTUCTIONS
submit ore form. !,
9.Total well depth below land surface; 445 00 24a. For All Wells: Submit this'torm within 30 days of completion of well
For multiple wells list all depths ifdIerent(example-3 a200'and 2Q100) construction to the following:
10.Static water level below top of casing: 58 (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 24b.For infection Wells ONLY: In Iaddition to sending the form to the address in
Rotary 24a above, also submit a copy of thi i form within 30 days of completion of well
12.Well construction method: construction to the following: i
(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) 1 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013