GW1--05076_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:
14.WATER ZONES r
Dwight L. Huneycutt FROM TO DESCRIPTION
Well Contractor Name 110 ft- 115 . ft- 3 gpm
4070-A 235 ft 240 IL 1 ; 3 gpm
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. o ft• 62 ft 6 1/8 'in- SDR-21 PVC •
Company Name r�r� 16.INNER CASING OR TUBING(geothermal closed-loop)
2022005w FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Munici al/Public
: °� a ft ft in.
❑Geothermal(Heating/Cooling Supply) ORes s tial4ater 5up�(ir(�i g('e;`°°1
❑Industrial/Commercial ❑Residential Water Supply(shi12&t ' 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation AUG 0 !t 2023 0 ft 3 ft- Bent.Chipsc Gravity
Non-Water Supply Well: 4 3 ft 20 ft- Bentonite Pumped
❑Monitoring Ol ot%iry,�,/cn Pr,-rg,�. 3� i jell
Injection Well: DW - ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑A ulfeC Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL EMPLACEMENT METHOD
q g tY ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft IL
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUroek type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 23 ft- Red Dirt
4.Date Well(s)Completed: 12/3/22 Well ID# 23 ft 41 ft Brown Dirt
41 ft- 54 ft- Brown Rock
5a.Well Location: 54 ft- 300 ft- Slate
Ricky Moody ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft ft. Seams:75',
571 Green Gap Shores, Troy 27371 ft ft 88', 11o'=3gpm, 129',
235'=3gpm
Physical Address,City,and Zip 21.REMARKS •
Montgomery 6589-00-77-5936
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)
N W Z7GU '/. 12/30/22
Signature of tertified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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#21 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: 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: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiiferent(example-3(200'and 2(4100) construction to the following:
10.Static water level below top of casing:
38 (f.) Division pf Water Resources,Information Processing Unit,
Ifwater 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:
(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
13a.Yield(gpm) 6 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