GW1-2023-02699_Well Construction - GW1_20230411

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Huneycutt 14.WATERZONES
John W. k I
FROM TO DESCRIPTION i
Well Contractor Name 178 ft 185 30 gpm
2465-A _ ft R.
NC Well Contractor Certification Number F_,._, a `" ^ 15.OUTER CASING for rnulfi-cased wells OR LINER if a Gcable
__..__ �•, ,�.• z ;�` "�.,�� ,! FROM TO DI MET
THICKNESS MATERIAL
Derry's Well Drilling, Inc. 0 fL 45 ft 6 1/8 1O SDR-21 PVC
Company Name 1 i LUZ3 16.iNNER CASING OR TUBING(geothermal closed-loop)
377639 FROM TO DL4METER THICK MESS MATERIAL
2.Well Construction Permit#: ft. ft in.
List all applicable well permits(.e_County,State,TarZR•e,lrije
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERL4L
❑Agricultural ❑Municipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hti ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 ft 20 ft. Bentonite Pumped
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable)'?
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft IA To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG(attack additional sheets if recess
[]Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,badness,soi0rock type.grain sae.etc) `
[]Geothermal(Reating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 12 ft Red Dirt
7/28/22 12 ft 27 ft Brown Dirt
4.Date Well(s)Completed: Well ID#
27 ft. 265 ft Blue Rock
5a.Well Location: ft ft
Tab Properties LLC ft. n
Seams:.50,, 152', 168', 178'=30gpm
Facility/Owner Name Facility ID#(if applicable)
ft ft.
S Oak Ridge Rd, Oakboro 28129 ft ft
Physical Address,City,and Zip
21.REMARKS
Stanly 28499
County Parcel identification No.(PIIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /
N W �.[�. 8/10122
Signature ofCettified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the trell(s)was(here)constructed in accordance
with 15A NGAC 02C.0100 or 15A NCAC 02C.t1200 Well Consrruction Standards and that a
7.Ts this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under 421 remarks.section or on the back of this firm. 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-crater supply we/Ls OM.Y frith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 265 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'anI2@100) construction to the following:
10.Static water level below top of casing: 22 (ft,) Division of Water Resources,Information Processing Unit,
If Crater level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection 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: iy 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) 30 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within.30 days of completion of
13b.Disinfection type: Granular Amount: 112 lb. well construction to the county health department of the county where
constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013