GW1-2023-01660_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
1.Well Contractor Information:
DerryDer L. Huneycutt 14.WATER ZONES i' t
Y FROM TO DESCRIPTION
Well Contractor Name ; °"� , 115 ft. 120 ft- 3 gpm
2663-A .;I C- 265 fL 270 fr. 3 gpm
15.OUTER CASING for multi=cased wells OR LINER if a licable
NC Well Contractor Certification Number t_ r 202�
v lr FROM TO DIAMETER I THICKNESS MATERIAL
Derry's Well Drilling, Inc. ln;�;,;,;r;;;� 60 ft. 6118 j SDR-21 PVC
Company Name C Yk' '` I�f/;j 16.INNER CASING OR TUBING eothermal closed-loop)
330573 ' a FROM TO DIAMETER TmCKNESS MATERIAL
2.Well Construction Permit#: ft ft. in
List all applicable well permits(i.e.County,State,Variance,bhjectton,etc.)
ft ft. "in.
3.Well Use(check well use): 17.SCREEN l'.
Water Supply Well: FROM TO DWHETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. % in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 fL Bent.Chips Gravity
Non-Water Supply Well:
3 fL 20 ft- gentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a tieable
FROM TO MATERIAL 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 neces
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardens,saturod e,grAn sing etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 10 ft. Red Dirt
4.Date Well(s)Completed: 4/6/22 Well ID# 10 ft- 35 % Brown Dirt
35 fL 300 rt Blue Rock
5a.Well Location: ft ft.
Lanny Howard
Facility/Owner Name Facility ID#(ifapplicable) % fL Seams:'67',75-77',80-86',105', 115'=3gpm,
Poplin Rd, New London 28127. ft. ft.
Physical Address,City,and zip i 125, 155,255,265-,_
3gpm
21.REMARKS
ARKS
139901
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 `th 4/25/22
Signature ofCcrtifi6d Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this forn;!•hereby certify that the well(s)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 [Z]No copy of this record has been provided to tine ivell owner.
if this is a repair,fill out known well construction information and explain the nature of the '
repair under#21 remarks sectlon 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
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
submit one form. SUBMITTAL INSTUCTIONS {,
9.Total well depth below land surface: 300 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple irells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 39 (ft.) Division of Water Resources,Information Processing Unit,
Ifivwer level is above casing,use '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: iln!addition to sending the form to the address in
Rotary 24aabove, also submit a copy of{his form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 6 Method of test: Air
24c.For Water Supply&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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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