GW1-2023-02622_Well Construction - GW1_20230410

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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:
Dwight L. Huneycutt FROM
TER ZONES f
ROM TO DESCRIPTION
Well Contractor Name iw•.' s ' c 175 ft' 180 ff 7gpm
4070-A p y (� fL ft.
NC Well Contractor Certification Number A r R t 0 2023 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. :_.� �.,, ,,_ , i t 1,., 0 ft 14s ft s 1is SDR-21 PVC
s,r _
Company Name "•,; "{)i;T~ 16.INNER CASING OR TUBING(geothermal closed-loop)
37341 FROM TO DIAMETER THICKNESS MA rF Rrer.
2.Well Construction Permit#: fr. ft. in.
List all applicable well permits(i.e.County,State,Variance,li jection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUL
R n in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft fG in
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fL 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 applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) pTracer FROM TO DESCRIPTION color,hardness,sailfrock a rain sire,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 21 ft. Red Clay
3/4/22 21 ft- 71 ft. Wet Red Dirt
4.Date Well(s)Completed: Well ID#
71 ft- 112 ft- Soft Brown Rock
5a.Well Location:
112 ft• 175 ft. Hard Brown Shale Rock
Cailyn Voss f� fr
Facility/OwuerName Facility ID#(ifapplicable) 175 245 Blue Rock
Allred Rd., Robbins, 27325 ft fL seams: 175'=7gpm, 190',227',234'
fr.. tL
Physical Address,City,and Zip 21.RE L4,RKS
Moore 00007401
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 W 12/31/22
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 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 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
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: 245 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (ft) Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection 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 following:
(i.e.auger,rotary,cabld,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) 7 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-I North Carolina Department ofEnvimnment and Natural Resources—Division of Water Resources Revised August 2013
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