GW1-2023-02655_Well Construction - GW1_20230411

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Derry L. Huneycutt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 750 ft- 758 ft
71. gpm
2663-A ft. &
15.OUTER CASING for multi-cased wells) LINER if a 'e FROM TO DIAMETER T. P!iV1.R1AL
NC Well Contractor Certification Number APR 2023 ER . 7
Derry's Well Drilling, Inc.;,_ ft- 45 ft 161/8 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER TtUC11[NESS MATERIAL
2.Well Construction Permit#: 22-357 ft. ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL IL in.
OAgricultural ElMunicipaL/Public
OGeothcrmal(Heating/Cooling Supply) R311esidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft' 3 ft- Bent.Chips Gravity
Non-Water Supply Well: 3 ft- 20 ft- Bentonite Pumped
OMonitoring CIRecovery
Injection Well: ft. %
OAquifcr Recharge OGroundwater Remediation -19.SAND/GRAVEL PACKif applicable)
OAquifer Storage and Recovery OSalinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
OAquifer Test DStortnwater Drainage ft it.
DExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft- 20 ft. Brown Dirt&Rock
4.Date Well(s)Completed: 9/28/22 Well ID4 2 20 it 900 It- Slate
ft. ft.
Sa.Well Location: R. ft.
Donnie Coleman ft. fL Seams:58',90',95', 120', 145',168',200',
Facility/Owner Name Facility ID#(if applicable) ft ft- 227',233',257�,318 350',418',454',665',
2115 Goose Creek Farm Ln,Indian Trail 28079(Goose Creek Farms Lt8) ft. ft, 730%750'=1 gpm,820',865' -
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:
(if well field,one lattlong is sufficient)
N W 10/15/22
Signature of Vxdfied Well Contractor I/ Date
6.Is(are)the well(s): 131'erimment or OTemporary By signing this form,I hereby certify that the well(s)it-as(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: 11Yes or EINo 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 421 remarks section or on the back of thisform. 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: 900 (ft.) 24a. For All Wells': Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdfferent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 150 (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
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,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) Method of test: Air 24c.For Water Supply&bjection Wells:
Also submit one copy of this form within 30 days of completion of
Granular mount: 1/2 lb. we construction o the county ea de
13b.Disinfection type: A well to t health ,partment of the county where
constructed.
Form GW­I North Carolina Department of Environment and Natural Resources-Di sees Revised August 2013