GW1--05067_Well Construction - GW1_20230804

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
John W. Huneycutt .14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name 380 R• 390 a• 6 gpm
2465-A `'Z L t%.a 1.i �� .; 47 n 552 2 gpm
NC Well Contractor Certification Number �'.15.OUTER CASING(for multi-cased wells)OR LINER(if ap lkeable) . -
AUG 0 �! 2023 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft 46 ft 6 1/8 ln• SDR-21 PVC
Company Name `� 16.INNER CASING OR TUBING(geothermal closed-loop)
383560 inform `n Pr 'edg UfctFROM TO DIAMETER THICKNESS , MATERIAL
V7a2.Well Construction Permit#: D + ft ft - in.
Listall 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 DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUpublic ft ft. in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ethrigation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
[Monitoring DRecovery 3 ft• 20 ft• 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
f. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) -
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type,grain she.etc.)
flGeotherrnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 5 ft. Red Dirt
12/8/22 5 ft 25 ft Brown Dirt
4.Date Well(s)Completed: Well 1D# -
25 ft. 600 ft Blue Rock
5a.Well Location: ft ft
Lane/Nicole Key •
Seams:70',82',95', 108', 135',210',235',
Facility/Owner Name Facility IINI(if applicable)
150 Stillwater Rd, Richfield 28137 ft rr. 290',307,330',370',380'=6gpm,432',
ft. ft 465',547'=2gpm
Physical Address,City,and Zip .
21.RE!<IARKS
Rowan 530E076
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) /� ,� JJ
N W Wll 1/20/23
Signs ofCertifted Well Contractor Date
6.Is(are)the well(s): 171Permanent or ❑Temporary By signing this form,I hereby certtt&that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7,Ts this a repair to an existing well: ❑Yes or ONo 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 o21 remarks section or an 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: 600 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2C4)100) construction to the following: •
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use•• " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
'FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m 8 Method of test: Air 24c.For Water Supply&Injection Wells:
(gpm) 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 depamnent of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013