GW1-2021-04515_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Internal Use ONLY: 6
This form can be used for single or multiple wells
1.Well Contractor IDformation:
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Der L. Huneycutt 14.WATERZONES
Derry Y FROM TO DESCRIPTION
Well Contractor Name 172 ft- 180 1- 1 20 gpm
2663-A ft. ft.
NC Well Contractor Certification Number 2021 15.OUTER CASING for multi cased Aells OR LINER if a ticable
ppR `� 9 i1 FROM TO DIAMETER THICKNESS MATERIAL
Derry's Well Drilling, Inc. nress1119V(ti 0 ft. 154 ft 61/8 in SDR-21 I PVC
Company Name ,. (r;3' er t!0 16.INNER CASING OR TUBING(geothermal dosed-loo
20-179 �i'3�f DvN�s FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.Count);State,Variance,Injection,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Bent.Chips Gravity
Non-Water Supply Well:
3 ft- 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ticable
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fa ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Fxperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Gcotherrnal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soit/rock type,grain i etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 3 ft. Red Dirt
4.Date Well(s)Completed: 1/155/21 Well ID# 3 fL 11 ft Brown Dirt
11 ft• 200 ft. Slate
5a.Well Location: tt. ft.
RHH of Union LLC & ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8222 Old Ferry Rd., Monroe 28110 (Old Ferry Est. Lt 5) Seams: 79', 114', 172'=tog
ft. ft.
Physical Address,City,and Zip 21.REMARKS
Union 08-120-033D
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W
Signature ofC64ified 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Hell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to thelwell ourer.
If this is a repair,fill ont known well construction information and explain the nature of the
repair under 421 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,yells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 200 (ft.) 24a. For All Wells: Submit this fiirm within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
21 Division of Water Resources,Information Processing Unit,
(ft.)
tf,vater level is above casing,nse"+ 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
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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent,er Raleigh,NC 27699-1636
13a.Yield(gpm) 20 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resoiuces Revised August 2013
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