GW1-2023-02619_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES 1
G Dwight L. Huneycutt _ FROM TO DESCRIPTION,
y. 226 229 rt• 2 m
Well Contractor Name gp
4070-A p zZ "" 355 fr 360 fr 3 gpm
NC Well Contractor Certification Number APR R ? Z1r23 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DLIMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. ,;;,, - ,;, _^ _ 0 fr 1107 ft- 6 1/8 SDR-21 I PVC
Company Name
r;l _:- ;;j•,.;, 16.INNER CASING ORTUBING(geothermal closed-loop)
�.,,�,,,�.,:ti�
43073 FROM TO DIAMETER THICKNESS nATERIAL
2.Well Construction Permit#: ft. tr. iv.
List all applicable well permits(i.e.County,State,Variance,b ffection,etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE TIHCKNESS MATERIAL
rn
[?]Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ohTi ation 0 ft. 3 fi- Bent.Chips Gravity
Non-Water Supply Well:
3 tt 20 tr Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
CEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL EMPLA METHOD
fL
❑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 tutor,hardness,soil/rock e•grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 12 ft Yellow Sand
12/19/22 12 ft. 29 ft. Wet Sand
4.Date Well(s)Completed: Well ID#
29 ft. 68 ft. White 8,Yellow Clay
Sa.Well Location: 68 fl- 85 ' ft. Red Clay
Michael Walters
85 ft• 95 tc White Clay
Facility/Owner Name Facility ID#(if applicable)
300 Keith Ln Pinebluff 28373 95 ft. 500 ft-, Gray Granite
+ ft, ft.
Physical Address,City,and Zip 21.REMARKS
Moore 20210114 Seams:226-229'=2gpm,236',248',294',355'=3gpm
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) L/
N W
12/31/22
Signature of Certified Well Contractor V Date
6.15(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1 5A 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 owner.
If this is a repair,fill out known well construction information and explain the nature of the
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
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
9.Total well depth below land surface: 500 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 40 (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter, 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, also submit a copy of this'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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 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 Ib• well construction to the county health(department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of water Resources Revised August 2013