GW1-2021-05878_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Dwight L. Huneycutt FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. &
4070-A C �� ft. ft. i
NC Well Contractor Cert fication Num t)O�� 15.OUTER CASING for multi cased wells OR LINER if a livable
y FAOM TO DIAMETER TRICKINESS MATERIAL.
Derry's Well Drilling, Inc. ��L 9 n�y��ti 0 fl 45 ft 61/8 '- 1 SDR-21 I PVC
i
Company Name ��Qr+ 16.INNER CASING OR TUBING(geothermal dosed-loop)
(n] �(] FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 4:?r4�r3 1"NR tr. fr. in
List all applicable ivell permits(i.e.County,Slate,1 ariance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply R'ell: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 fL 3 ft Bent.Chips Gravity
Non-Water Supply Well:
3 ft 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
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 ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. tL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gmin sim,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 ismi 0 ft. 11 ft. Brown Dirt
11 ft- 23 ft. Brown Rock
4.Date wells)Completed: 5/5/21 ]pe111TNt 1 23 ft- 725 ft. Slate
5a.Well Location: ft. ft.
Bobby&Tiffany Robinson fr. ft.
Facility/Owner Name Facility M4(ifapplicable) IL ft
4616 Old Pageland Monroe Rd., Monroe 28112 ft. ft. Seams:56', 112', 167', 178', 197',250'
Physical Address,City,and Zip 21 REMARKS
Union 03126017A Well is very low yield,but does produce some water,however
Comity Parcel identification No.(PiN) not sustainable for a household.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one lat/long is sufficient)
N W D ,�, 6/1/21
Signature dVCertitied Well Contractor Date
6.1s(are)the well(s): OPermanent or ❑Temporary By,signing this form, I hereby certify that the well(s)was(were)constructed in accordance
with i5A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
/fthis is a repair,fill out known well construction information and explain the nature ofthe
repair under h1l 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor multiple injection or non-water supply wells ONLY with the.same construction,you can
submit one farm. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 725 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Ivor multiple wells list all depths ifdiereni(example-3@200'and 2@i00) construction to the following.
10.Static water level below top of easing: 50 (g•) Division of Water Resources,information Processing Unit,
/fwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
It.Borehole diameter: 6 (in.) 24b.For injection Wells ONLY: in addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: f
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seimice Center,Raleigh,NC 27699-1636
13a.]'field(gpm) N/A Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form i 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