GW1-2023-02646_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt 1FROM4.WATER ZONES
TO DESCRIP77ON
Well Contractor Name ft' 540 H'530 1/2 gpm
2663-A ft. ft.
APR 15.OUTER CASING for 0 cable)
NC Well Contractor Certification Number
Derry's Well Drilling, Inc. 2023 FROM TO T!LIUMECTEWRCUS) MATERIAL
0 fr145 f1 61/8 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 4: 22-54 FROM ft. TO ft. DIAMETER THICKNESS MATERIAL
in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DL4d1IETER SLOT SIZE THICKNESS MATERIAL
ft IL in.
DAgricultural OMunicipal/Public
DGeothermal(Heating/Cooling Supply) VIResidential Water Supply(single) M ft. in.
01ndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft 20 ft- Bentonite Pumped
OMonitoring ORecovery
Injection Well: ft. ft.
CAquifer Recharge OGroundwater Remediation 19.SANDIGRAVEL PACK017 applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier ft ft.
DAquifier Test ElStormwater Drainage
DExperimental Technology OSubsidence Control ft. ft.
20.DRILLING LOG attach additional sheets if necessary)
DGeothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks 0 ft- 215 ft. Brown Dirt&Rock
4.Date Well(s)Completed: 9/22/22 Well ID# 25 ft 600 ft slate
ft. ft.
Sa.Well Location: ft. ft.
Donnie Coleman ft Ifr
Facility/Owner Name Facility M#(if applicable)
2115 Goose Creek Farm Ln, Indian Trail 28079 ft Seams:70',95', 105',200',325',456',
ft ft. 470',530'=1/2gpm
Physical Address,City,and Zip 21.REMARKS
Union 08-291-020M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifivell field,one Wong is sufficient)
N W Q�r10/15/22
Signature ofCcVdfiedWell Contractor Date
6.1s(are)the well(s). ©Permanent or Ofemporary By signing this form,I 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: OYes or E]No 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:
1 You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 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 forum. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 200 (ft) Division of Water Resources,Information Processing Unit,
Ifirater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For infection Wells ONLY: In addition to sending the form to the address in
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:
(Le.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
1 i
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 lb• well construction to the county health'department of the countywhere
constructed. I i
Form GW-I North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013