GW1-2021-05835_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For internal Use ONLY: !
This form can be used for single at multiple wells
I.Well Contractor information:
Dwight L. Huneycutt IM C CF NED 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 302 f" 310 ft. j 2 gpm
4070-A AL 0 9 2021 ft. ft.
NC Well Contractor Certification Number 'ntOiC"3t10n prooesSing knit FROMUTER CASING for mulctsRells OR TE 1Rf a iicatbAl7eERIAL
Derry's Well Drilling, Inc. p%NR Secii°n 0 ft 53 ft 6118AME '- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermat dosed-loop)
21-102 PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: & ft. is
List all applicable well permits ri.e.County,Slate,Variance,Injection,etc.)
& & in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. rn
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 fL 3 f1- Bent.Chips Gravity
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fL 35 ft. Bentonite Pumped
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVELPACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO DiATER(AL EMPLACEMFdVT DIETHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
& ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Color•balloess soillrock type,gmin size,etc
❑Geothermal Heating/Cooling Return) ❑Ether(explain under 421 Remarks) 0 fit- 16 ft. Brown Dirt
5/4/21 16 rt 26 ft. Brown Rock
4.Date Wells)Completed: Well ID#
26 fL 445 ft- Slate
Sa.Well Location: fL ft.
Ronnie Laney fL ft.
Facility/Owner Name Facility to#(if applicable) fL fL Seams:77',84-90', 135', 172',295'
Pigg Mattox Rd, Monroe 28112 ft. ft. 302'=2g
Physical Address,City,and Zip 21.REMARKS
Union 04072015H
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(ifwell field one Wong is sufficient)
N W 5/14/21
Signatureo ertitied Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this franc,1 hereby certify tha('the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy of this record hav been provided to the well(Amer.
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under ii21 remarks section or on the back ofthis 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: 445 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-or multiple wells list all depths ifdoerem(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 38 (ft.) Division of Water Resources,information Processing Unit,
Ifuaterlevel is abme casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
.e.auger,rotary,
('r g fury,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
24c.For Water Supply&Injectlon(Wells:
13a.field(gpm) 2 Method of test: Air ,
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 Ib. well construction to the county health'department of the county where
constructed.
r
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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