GW1-2023-02713_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:
Dwight L. Huneycutt 14•WATERZONES
Y FROM TO DESCRIPTION
ll Contractor Name 115 ft 120 ft.
We 5 gpm
4070-A
ft. ft
NC Well Contractor Certification Number ''"' 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. APR 1 1 2Q23 0 ft 76 ft- 61/8 'n I SDR-21 I PVC
Company Name I :S 16.INNER CASING OR TUBING eothermal closed-loop)
.,•� is FROM TO DIAMETER THICKNESS MATE
355656 RIAL
In ;r;l -', :� N,
2.Well Construction Permit#: 1t. 1t. in.
List all applicable well permits(i.e.County,State,I,arlance,Injection,etc.)
ft ft in,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERrar.
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) ZIResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 it" 3 ft- Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 20 ft- BentonitePumped
❑Monitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO n MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRn'1'ION(color,hardness,soNrock type rain sue,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f• 25 ft. Wet Brown Dirt
4.Date Well(s)Completed: 10/6/22 Well ID# 25 ft- 50 ft Brown Dirt
50 ft. 66 ft. Brown Granite
5a.Well Location: 66 ft 245 ft Blue Granite
Ken Morrison ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Rockwell Rd., Rockwell 28138 ft f` Seams:80',ss',s5', 115'=59pm
f4 ft.
Physical Address,City,and Zip 21.REMARKS
Rowan 377 030
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one huhang is sufficient)
N W Tyr u�,gfit,L_. 8/30/22
Signature ofterdfied Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cer16 that lire well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑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 421 remarks section or on the back of this 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 ifdifferent(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwa(erlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.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: 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 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(,-pm) 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 county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013